What is the recommended treatment for a 19-year-old patient with a sore throat, mainly when swallowing, and possible pus pockets, suggestive of strep throat, but with improving symptoms?

Management of Suspected Streptococcal Pharyngitis in a 19-Year-Old with Improving Symptoms

For this 19-year-old with sore throat and possible tonsillar exudates but improving symptoms, perform a rapid antigen detection test (RADT) or throat culture to guide antibiotic decision-making rather than treating empirically or withholding testing. 1

Diagnostic Approach

Clinical assessment alone cannot reliably distinguish streptococcal from viral pharyngitis, even when exudates are present—microbiological confirmation is required. 1

Apply the Centor Criteria to Guide Testing Strategy

Calculate the modified Centor score based on:

• Fever (temperature >100.4°F/38°C)
• Tonsillar exudates (the "pus pockets" mother observed)
• Tender anterior cervical lymphadenopathy
• Absence of cough
• Age 15-44 years (adds 1 point; this patient is 19) 1, 2

Testing recommendations based on score:

• 0-1 criteria: No testing or antibiotics needed 1
• 2-3 criteria: Perform RADT or throat culture 1
• 4+ criteria: Consider RADT; may discuss empiric antibiotics while awaiting results 1

Testing Method Selection

For adults (including this 19-year-old), a negative RADT does NOT require backup throat culture because the incidence of Group A streptococcus is lower in adults (5-15%) and rheumatic fever risk is exceptionally low. 1, 3 However, if you want maximal diagnostic sensitivity, you may back up negative RADTs with culture. 1

A positive RADT is highly specific and does not require culture confirmation—proceed directly to treatment. 1

Treatment Decision Algorithm

If RADT/Culture is Positive for Group A Streptococcus:

Prescribe penicillin V (250 mg three times daily or 500 mg twice daily) for 10 days, which remains the treatment of choice due to proven efficacy, safety, narrow spectrum, and low cost. 1

Alternative options:

• Amoxicillin (equally effective and more palatable than penicillin) 4, 2
• Intramuscular benzathine penicillin G (single injection) if compliance with 10-day oral therapy is questionable 1, 2
• First-generation cephalosporins for penicillin-allergic patients without immediate hypersensitivity 1, 4
• Azithromycin (12 mg/kg once daily for 5 days, maximum 500 mg/day) demonstrated 95% bacteriologic eradication and 98% clinical success at Day 14 in pharyngitis trials 5
• Erythromycin for true penicillin allergy 1

If RADT/Culture is Negative:

Do not prescribe antibiotics. Antibiotics should not be used in patients with less severe presentations (0-2 Centor criteria) to relieve symptoms. 1

Symptomatic Management (Regardless of Test Results)

Prescribe ibuprofen or acetaminophen (paracetamol) for symptom relief—these are the most effective treatments available for sore throat pain. 1, 3

Corticosteroids are NOT routinely recommended but can be considered in adults with severe presentations (3-4 Centor criteria) in conjunction with antibiotics. 1, 6 Given this patient's improving symptoms, steroids are not indicated. 6

Key Clinical Considerations for This Case

The improving symptom trajectory is reassuring but does not eliminate the need for testing if clinical criteria suggest possible streptococcal infection. 1 Viral pharyngitis typically improves within 7 days without antibiotics. 3

Common pitfall to avoid: Do not prescribe antibiotics empirically based solely on the presence of exudates or parental concern—65-85% of acute pharyngitis cases are viral. 3 Even patients with all clinical features of streptococcal pharyngitis are confirmed to have Group A streptococcus only 35-50% of the time. 1

Antibiotics are NOT needed to prevent complications (rheumatic fever, glomerulonephritis, peritonsillar abscess, otitis media) in low-risk patients without previous rheumatic fever. 1, 3

Do not perform routine follow-up testing after successful completion of antibiotic therapy in asymptomatic patients. 1