Time Course of Strep Throat Without Antibiotics
Without antibiotic treatment, the typical course of strep throat is less than one week, with most symptoms resolving spontaneously within 3-4 days of onset. 1
Natural Course of Strep Throat
- Fever and constitutional symptoms typically disappear spontaneously within 3-4 days of onset, even without antimicrobial therapy 1
- By one week, approximately 82% of untreated patients will be symptom-free 2
- Sore throat symptoms tend to be most severe in the first 2-3 days and gradually improve thereafter 1
Symptom Resolution Timeline
- Day 3: Most patients begin experiencing significant symptom improvement 2
- Day 7: The majority of patients (>80%) will have complete resolution of symptoms 1, 2
- Without antibiotics, throat soreness typically lasts 1-2 days longer compared to those receiving antibiotic treatment 1
Risks of Non-Treatment
Suppurative Complications
- Peritonsillar abscess (quinsy): Rare but possible complication without antibiotic treatment 1, 2
- Studies show approximately 1-2% of untreated cases may develop this complication 2
- Acute otitis media: Can occur as a complication within 14 days of onset 2
- Cervical lymphadenitis: May develop in some untreated cases 1
Non-Suppurative Complications
- Acute rheumatic fever: Historical concern but extremely rare in developed countries today 1
- Most common in children and adolescents rather than adults 1
- Acute glomerulonephritis: Very rare complication that may occur even with antibiotic treatment 1
Comparison to Antibiotic Treatment
- Antibiotics shorten the duration of sore throat by only 1-2 days compared to no treatment 1
- The number needed to treat (NNT) to reduce symptoms is 6 after 3 days of treatment and 21 after 1 week 1
- Antibiotics reduce the risk of suppurative complications but the absolute risk reduction is small 1, 2
- The benefit of antibiotics must be weighed against potential side effects, impact on microbiota, and contribution to antibiotic resistance 1
Clinical Implications
- For most healthy adults with mild symptoms, watchful waiting is a reasonable approach 1
- Symptomatic treatment with analgesics (aspirin, acetaminophen, NSAIDs) and throat lozenges can help reduce pain during the natural course of the illness 1
- Patients with severe symptoms or high-risk factors (history of rheumatic fever) should still be considered for antibiotic therapy 1
- Clinical deterioration during the natural course warrants reassessment, as approximately 13% of untreated patients may require antibiotics later due to worsening symptoms 3
Common Pitfalls
- Assuming all sore throats are streptococcal in origin - most are viral and will resolve without antibiotics 1
- Overlooking severe presentations that may indicate complications requiring immediate intervention (difficulty swallowing, drooling, neck tenderness/swelling) 1
- Failing to recognize that bacterial eradication rates without antibiotics are low (approximately 7%), which may lead to carrier state or delayed complications in high-risk populations 3