Does all strep throat require antibiotics to recover?

Does All Strep Throat Need Antibiotics to Get Better?

No, strep throat does not require antibiotics to resolve—most cases will improve spontaneously within 3-4 days, with complete symptom resolution typically occurring within one week even without treatment. 1

Natural Resolution Without Antibiotics

The evidence clearly demonstrates that streptococcal pharyngitis is a self-limited condition:

• Fever and constitutional symptoms disappear spontaneously within 3-4 days of onset, even without antimicrobial therapy 1
• Throat soreness lasts only 1-2 days longer in untreated patients compared to those receiving antibiotics 2, 1
• By one week, the majority (>80%) of patients achieve complete symptom resolution regardless of antibiotic use 1

The modest benefit of antibiotics translates to shortening symptom duration by only 1-2 days, with a number needed to treat (NNT) of 6 after 3 days and 21 after 1 week 2, 1. This means you must treat 6 patients to prevent one person from having symptoms at day 3, and 21 patients to prevent symptoms at one week.

When Antibiotics Should Be Used

Despite natural resolution being the norm, antibiotics are indicated in specific circumstances based on current guidelines:

Testing-Based Approach

• Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (persistent fevers, anterior cervical adenitis, tonsillopharyngeal exudates) by rapid antigen detection test and/or culture 2
• Treat with antibiotics only if streptococcal pharyngitis is confirmed by testing 2

Severity-Based Stratification

• Patients with 0-2 Centor criteria should NOT receive antibiotics for symptom relief 2
• Patients with 3-4 Centor criteria may be considered for antibiotics after discussing the modest benefits versus risks (side effects, microbiota disruption, antibiotic resistance) 2

Primary Justifications for Antibiotic Treatment

The rationale for treating confirmed strep throat has shifted significantly in modern practice:

Complication Prevention (Limited Benefit)

• Antibiotics should NOT be used to prevent rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous history of rheumatic fever) 2
• Prevention of suppurative complications (quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis) is NOT a specific indication for antibiotic therapy 2
• Acute rheumatic fever is extremely rare in developed countries today, affecting mostly children and adolescents 1
• Acute glomerulonephritis is very rare and may occur even with antibiotic treatment 1

Symptom Reduction (Modest Benefit)

The primary remaining justification for antibiotics is modest symptom reduction, but this must be weighed against:

• Antibiotic side effects 2
• Impact on normal microbiota 2
• Contribution to antibiotic resistance 2
• Medicalization and costs 2

Recommended Management Algorithm

For Patients with Mild Symptoms (0-2 Centor Criteria)

• Do NOT prescribe antibiotics 2
• Offer analgesic therapy: ibuprofen or acetaminophen for pain relief 2
• Reassure patients that typical sore throat duration is less than one week 2

For Patients with Severe Symptoms (3-4 Centor Criteria)

• Perform rapid antigen detection test or throat culture 2
• If positive for group A Streptococcus: discuss modest benefits (1-2 day symptom reduction) versus risks with patient 2
• If antibiotics are chosen: prescribe penicillin V 250-500mg twice or three times daily for 10 days 2, 3

For High-Risk Patients

• Patients with previous history of rheumatic fever should receive antibiotics for confirmed strep throat 2
• Severe presentations warrant consideration of antibiotic therapy 2

Common Pitfalls to Avoid

• Do NOT assume all sore throats are streptococcal—most are viral and will resolve without antibiotics 1
• Do NOT prescribe antibiotics empirically without testing for group A Streptococcus 2
• Do NOT treat asymptomatic carriers—they are unlikely to spread infection and are at little or no risk for complications 2
• Do NOT perform follow-up throat cultures after completing treatment in patients who have successfully completed therapy 4
• Do NOT overlook severe presentations that may indicate complications requiring immediate intervention (peritonsillar abscess, Lemierre syndrome) 2

Recent High-Quality Evidence

A 2024 randomized controlled trial in children demonstrated that placebo was non-inferior to amoxicillin in reducing fever duration, with similar pain intensity and complication rates between groups 5. This supports a more restrictive approach to antibiotic prescribing for streptococcal pharyngitis in high-income countries where suppurative complications can be promptly treated if they arise.