What is the first-line treatment for a child with streptococcal pharyngitis (strep throat) or viral pharyngitis presenting with a swollen red sore throat?

First-Line Treatment for a Child with Swollen Red Sore Throat

For a child with a swollen red sore throat, start with symptomatic treatment using ibuprofen or acetaminophen for pain relief, and only prescribe antibiotics after confirming bacterial infection through rapid antigen testing or throat culture. 1

Initial Approach: Determine If Testing Is Needed

Most sore throats in children are viral and do not require antibiotics. 1 The key decision is whether the clinical presentation warrants testing for Group A streptococcal (GAS) infection.

Do NOT test or treat if viral features are present: 1

• Cough
• Runny nose (coryza)
• Hoarseness
• Conjunctivitis
• Diarrhea
• Discrete oral ulcers

Consider testing if the child has features suggesting bacterial infection (Centor criteria): 1

• Fever (especially >38.5°C)
• Tonsillar exudates or swelling
• Tender anterior cervical lymph nodes
• Absence of cough

Diagnostic Testing Strategy

For children with 3-4 Centor criteria, perform a rapid antigen detection test (RADT). 1 If the RADT is positive, this confirms GAS pharyngitis and treatment should begin. 1

If the RADT is negative in children and adolescents, perform a backup throat culture because the sensitivity of RADT is not perfect and missing GAS infection carries risk of rheumatic fever in this age group. 1 This backup culture is critical—adults may not need it due to lower rheumatic fever risk, but children do. 1

Important caveat for children under 3 years: GAS pharyngitis is uncommon in this age group and presents differently (mucopurulent rhinitis, excoriated nares, rarely exudative pharyngitis). 1 Testing is generally not recommended unless there are specific risk factors like an older sibling with confirmed strep throat. 1

First-Line Antibiotic Treatment (Once GAS Confirmed)

If GAS pharyngitis is confirmed, prescribe oral penicillin V or amoxicillin for 10 days. 1, 2

Preferred Regimens:

• Penicillin V: 250 mg twice or three times daily for 10 days 1, 2
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 2
• Intramuscular benzathine penicillin G: Single dose of 600,000 units for children <27 kg or 1,200,000 units for children ≥27 kg (useful if compliance is a concern) 2

Amoxicillin is often preferred over penicillin V due to better palatability in children, which improves adherence. 3, 4

For Penicillin-Allergic Patients:

Non-anaphylactic allergy (e.g., rash): 2

• Cephalexin 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days
• Cefadroxil 30 mg/kg once daily (maximum 1 g) for 10 days

Anaphylactic allergy (Type I hypersensitivity): 2

• Clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days
• Clarithromycin 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days

Critical point: Macrolides (azithromycin, clarithromycin) should be reserved for true penicillin allergy due to increasing resistance in some regions. 3, 4

Symptomatic Treatment (For All Children)

Regardless of whether antibiotics are prescribed, provide symptomatic relief: 1, 2

• Ibuprofen or acetaminophen for pain and fever control
• Never use aspirin in children due to risk of Reye syndrome 1, 2
• Encourage adequate hydration and rest 2

NSAIDs (like ibuprofen) are more effective than acetaminophen for throat pain relief. 5

Critical Treatment Principles

The full 10-day course must be completed even if symptoms resolve earlier, as this is essential to prevent acute rheumatic fever. 2, 3 Treatment should be initiated within 9 days of symptom onset to effectively prevent this complication. 2

Do not prescribe antibiotics without confirming the diagnosis through testing, as this contributes to antimicrobial resistance and treats the majority of children (who have viral pharyngitis) unnecessarily. 1 The modest benefits of antibiotics in confirmed cases must be weighed against side effects, effects on the microbiome, and increased resistance. 1

Follow-Up

Routine post-treatment testing is not recommended unless symptoms persist beyond 48-72 hours or recur, which may suggest treatment failure or a suppurative complication. 1, 2

Do not test or treat asymptomatic household contacts as this has not been shown to reduce secondary illness rates and leads to unnecessary antibiotic exposure. 1