What is the treatment for a sore throat with negative COVID-19 (Coronavirus Disease 2019), RSV (Respiratory Syncytial Virus), and strep (Streptococcal) swabs?

Treatment for Sore Throat with Negative COVID-19, RSV, and Strep Swabs

For sore throat with negative COVID-19, RSV, and strep swabs, symptomatic treatment with ibuprofen and adequate hydration is the first-line approach, with antibiotics only considered if clinical suspicion for bacterial infection remains high despite negative tests. 1

Symptomatic Treatment (First-Line)

• For fever >38.5°C: Ibuprofen 200mg orally every 4-6 hours (not exceeding 4 times in 24 hours) is recommended for symptomatic relief 1, 2
• Ensure adequate hydration and nutrition with protein-rich foods to support immune function 1, 2
• Rest is essential to allow the body to recover from the infection 2
• Over-the-counter throat lozenges, warm salt water gargles, and honey (in non-diabetic adults) can provide additional symptomatic relief 1

When to Consider Antibiotics

Despite negative rapid tests, antibiotics may be considered in certain situations:

• If clinical presentation strongly suggests bacterial infection (fever, white tonsillar exudate, absence of cough, tender anterior cervical lymphadenopathy) 1, 3
• If symptoms are severe or persistent beyond 5-7 days 3
• If patient has high-risk features (immunocompromised, history of rheumatic fever) 4

Antibiotic Options When Clinically Indicated

• First-line: Azithromycin is recommended when clinical suspicion for bacterial pharyngitis remains high despite negative tests 1
• Alternatives: Amoxicillin or fluoroquinolones if azithromycin is contraindicated 1
• Duration: 5-7 days of treatment is typically sufficient 3

Clinical Decision Making

Clinical scoring systems can help guide treatment decisions when test results are negative but clinical suspicion remains:

• Centor or McIsaac scores ≥3 points may warrant consideration of antibiotics despite negative testing (due to potential false negatives) 3
• Low scores (<3 points) suggest viral etiology, and antibiotics should be avoided 3

Monitoring and Follow-up

• Most viral and bacterial sore throats are self-limiting with a mean duration of 7 days 3
• If symptoms do not improve within 48-72 hours of starting treatment, re-evaluation is necessary 1
• Monitor for development of complications such as peritonsillar abscess (quinsy), which would require more aggressive intervention 4

Important Considerations

• Antibiotics only modestly reduce symptom duration (by approximately one day) even in bacterial cases 4
• Unnecessary antibiotic use contributes to antimicrobial resistance and should be avoided when possible 3
• The presence of white tonsillar exudate may suggest bacterial infection even with negative rapid tests (which can have false negatives) 1
• Most sore throats (>65%) are viral in nature and will resolve without antibiotics 3, 5

Special Situations

• For patients with recurrent symptoms, consider additional testing for less common pathogens 5
• In patients with severe symptoms or high-risk features, a lower threshold for antibiotic therapy may be appropriate despite negative tests 4
• Consider povidone-iodine mouth or nasal spray as an adjunctive treatment to reduce viral load in the pharynx 6