What is the treatment for acute pharyngitis?

Treatment of Acute Pharyngitis

For acute pharyngitis, penicillin V (oral) for 10 days is the treatment of choice for confirmed Group A Streptococcal (GAS) pharyngitis due to its proven efficacy, safety, narrow spectrum, and low cost. 1

Diagnostic Approach

• Distinguish between viral and bacterial causes of pharyngitis, as most cases are viral but GAS is the primary bacterial pathogen requiring specific treatment 1
• Clinical features alone cannot reliably distinguish between viral and bacterial causes, necessitating laboratory confirmation 1
• Diagnosis should be confirmed using either Rapid Antigen Detection Test (RADT) or throat culture 1
• Testing is not recommended when viral symptoms predominate (cough, rhinorrhea, hoarseness, oral ulcers) 2

Treatment for Confirmed GAS Pharyngitis

First-line Treatment

• Penicillin V (oral) for 10 days is the treatment of choice for GAS pharyngitis 1, 3
• For patients unlikely to complete a full 10-day course of oral therapy, intramuscular benzathine penicillin G as a single dose is recommended 1

Alternative Treatment Options

• For non-anaphylactic penicillin allergy: First-generation cephalosporins (e.g., cephalexin) 1
• For anaphylactic penicillin allergy: Clindamycin or macrolides (azithromycin or clarithromycin) 1, 4
• Azithromycin has shown clinical success rates of 95% for bacteriologic eradication and 98% for clinical success in streptococcal pharyngitis 4

Treatment Goals

• Primary goal: Prevent acute rheumatic fever and suppurative complications such as peritonsillar abscess 1
• Secondary goals: Reduce clinical symptoms, decrease duration of illness, reduce contagiousness, and prevent transmission 1

Non-GAS Pharyngitis

• Viral pharyngitis is self-limiting and requires only symptomatic treatment 1
• Group C and G streptococci can cause pharyngitis with similar clinical features to GAS but are not associated with acute rheumatic fever and typically don't require antibiotic treatment 1, 5
• Treatment of Group G streptococcal pharyngitis is not routinely recommended as it is not associated with acute rheumatic fever 5

Symptomatic Treatment

• Acetaminophen or NSAIDs for pain relief and fever reduction 1, 2
• Avoid aspirin in children due to risk of Reye syndrome 1
• Routine use of corticosteroids is not recommended 1, 2
• Warm salt water gargles may provide symptomatic relief 2

Management of Recurrent Episodes

• Consider whether the patient has true recurrent infections or is a chronic carrier experiencing viral infections 1
• Antibiotic treatment for chronic carriers is not recommended 1
• For true recurrent GAS pharyngitis, options include clindamycin, penicillin plus rifampin, or amoxicillin-clavulanate 1

Special Considerations

• Breastfeeding should continue during treatment to maintain milk supply and provide benefits to the infant 2
• Routine post-treatment testing is not recommended unless symptoms persist 2
• Household contacts of patients with GAS pharyngitis do not routinely require testing or empiric treatment 2

Common Pitfalls to Avoid

• Treating all pharyngitis cases with antibiotics without confirming bacterial etiology 6, 7
• Using broad-spectrum antibiotics unnecessarily when narrower spectrum options would be more appropriate 5
• Failing to distinguish between true infection and colonization/carrier state 5
• Not completing the full course of antibiotic therapy, which can lead to treatment failure and complications 1