What is the best treatment for pharyngitis?

Best Treatment for Pharyngitis

For confirmed Group A Streptococcal (GAS) pharyngitis, penicillin or amoxicillin for 10 days remains the treatment of choice due to proven efficacy, safety, narrow spectrum, and low cost. 1

Diagnostic Approach First

Before treating pharyngitis, proper diagnosis is essential:

• Laboratory confirmation is required because clinical symptoms of GAS and viral pharyngitis overlap broadly 1
• Use rapid antigen detection test (RADT) or throat culture in patients with clinical features suggesting bacterial infection 1
• In adults, a negative RADT is sufficient to rule out streptococcal pharyngitis without confirmatory culture 1, 2
• In children, confirm negative RADT with throat culture due to higher prevalence and rheumatic fever risk 1, 2
• Do not test children under 3 years old routinely, as GAS pharyngitis and rheumatic fever are rare in this age group 1

Treatment Algorithm for Confirmed GAS Pharyngitis

First-Line Antibiotic Therapy

For patients without penicillin allergy:

• Oral penicillin V or amoxicillin for 10 days is the standard of care 1
• Amoxicillin (50 mg/kg/day once daily, maximum 1000 mg) offers improved adherence with once-daily dosing 3
• Intramuscular benzathine penicillin G (600,000 U for <27 kg; 1,200,000 U for ≥27 kg) as single dose for patients unlikely to complete oral therapy 1, 3

Alternative Therapy for Penicillin Allergy

For non-anaphylactic penicillin allergy:

• First-generation cephalosporins for 10 days 1, 3

For immediate/anaphylactic penicillin allergy:

• Clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 3
• Clarithromycin for 10 days 1
• Azithromycin for 5 days (12 mg/kg once daily for children; 500 mg day 1, then 250 mg days 2-5 for adults) 1, 4

Important caveat: Macrolide resistance among GAS is approximately 5-8% in the United States, making clindamycin preferable when available 3

Treatment for Viral (Strep-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing 2

Symptomatic Management Only

• Ibuprofen or acetaminophen for moderate to severe symptoms or high fever 1, 2
• NSAIDs (ibuprofen) provide superior pain relief compared to acetaminophen in randomized controlled trials 1
• Avoid aspirin in children due to Reye syndrome risk 1
• Medicated throat lozenges every 2 hours can provide relief 5
• Warm salt water gargles (though not formally studied) 1

Do not use corticosteroids as adjunctive therapy—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects 1

Common Pitfalls to Avoid

• Never treat based on clinical symptoms alone without laboratory confirmation, as this leads to antibiotic overuse 2
• Do not use tetracyclines (high resistance rates), sulfonamides, trimethoprim-sulfamethoxazole (do not eradicate GAS), or older fluoroquinolones like ciprofloxacin (limited GAS activity) 1
• Do not perform routine follow-up throat cultures after completing therapy in asymptomatic patients 1
• Do not test or treat asymptomatic household contacts 1
• Do not switch antibiotics without microbiological indication, as this increases adverse effects without clinical benefit 2

Special Circumstances

Treatment Failures and Recurrent Episodes

If symptoms persist or recur shortly after completing therapy:

• Consider that patient may be a chronic GAS carrier experiencing viral infections rather than true recurrent GAS pharyngitis 1
• For symptomatic treatment failures, consider clindamycin, amoxicillin-clavulanate, or narrow-spectrum cephalosporin as these achieve higher eradication rates 1, 3
• Intramuscular benzathine penicillin G if oral compliance is questionable 1

Chronic Carriers

• Do not routinely identify or treat chronic GAS carriers as they are at little risk for complications or spreading infection 1
• Treatment of carriers is justified only in special circumstances: community outbreak of rheumatic fever, family history of rheumatic fever, or excessive family anxiety 1

Key Clinical Points

• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 3, 6
• The 10-day duration is necessary for maximal pharyngeal eradication with most antibiotics 1
• Primary goal of antibiotic treatment is preventing acute rheumatic fever, not just symptom relief 1, 3
• Group C and Group G streptococcal pharyngitis do not cause rheumatic fever and do not require the same treatment approach 1