Should most adult cases of streptococcal pharyngitis (strep throat) go untreated?

Should Adult Strep Throat Cases Go Untreated?

No, adult strep throat cases should not go untreated when Group A Streptococcus (GAS) infection is confirmed by testing, but the critical point is that most adults with pharyngitis do NOT have strep throat and should not receive antibiotics. 1

The Core Problem: Overtreatment is Rampant

• Only 5-15% of adult pharyngitis cases are actually caused by Group A Streptococcus, yet more than 60% of adults presenting with sore throat receive antibiotic prescriptions 1, 2, 3
• The vast majority of adult pharyngitis is viral and self-limited, resolving in less than one week without antibiotics 1, 4
• This represents massive overtreatment and inappropriate antibiotic use 1

When Treatment IS Indicated

Antibiotics should only be prescribed for adults with confirmed streptococcal pharyngitis by positive rapid antigen detection test (RADT) or throat culture 1

Benefits of Treating Confirmed GAS Pharyngitis:

• Antibiotics shorten symptom duration by only 1-2 days 1, 4
• The number needed to treat is 6 after 3 days and 21 after 1 week—modest benefit at best 1, 4
• The primary justification for treatment is preventing complications: peritonsillar abscess, spread to close contacts, and acute rheumatic fever (though rheumatic fever risk is extremely low in adults) 1, 5
• Antibiotics do NOT prevent acute glomerulonephritis 1

Treatment Regimen When Indicated:

• First-line: Penicillin or amoxicillin for 10 days to eradicate GAS from the pharynx and prevent acute rheumatic fever 1, 6, 2, 3
• First-generation cephalosporins for patients with non-anaphylactic penicillin allergy 2, 3
• Avoid macrolides (azithromycin, clarithromycin) due to significant resistance in many U.S. regions 2

The Algorithmic Approach to Adult Pharyngitis

Step 1: Clinical Screening

Use the Centor criteria to assess probability of GAS infection 7:

• History of fever
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough (cough suggests viral etiology) 2, 3

Step 2: Testing Strategy Based on Centor Score

• 0-1 criteria present: Do NOT test or treat—viral etiology most likely 7
• 2-3 criteria present: Perform RADT; treat only if positive 1, 7
• 4 criteria present: Either perform RADT or treat empirically (though testing preferred to avoid overtreatment) 7

Step 3: Testing Considerations for Adults

• Negative RADT does NOT require confirmatory throat culture in adults (unlike children), due to low prevalence of GAS and very low rheumatic fever risk 1
• The high specificity of RADT minimizes overprescription in adults 1
• Throat cultures are not recommended for routine primary evaluation of adults 7

Critical Pitfall: The Chronic Carrier Problem

• Adults can be chronic GAS carriers who experience repeated viral pharyngitis 5, 4
• Chronic carriers do NOT require antibiotic therapy—they are unlikely to spread infection and have minimal complication risk 1, 5
• Repeated courses of antibiotics without confirming bacterial etiology drives antimicrobial resistance 5
• A positive throat culture in a patient with persistent symptoms may indicate carrier state with concurrent viral infection, not active GAS infection 5

Symptomatic Management for All Patients

Every adult with pharyngitis should receive appropriate symptomatic care regardless of etiology 1, 7:

• NSAIDs or acetaminophen for pain and fever 1, 4, 3
• Throat lozenges 1, 3
• Salt water gargles 4
• Reassurance that typical pharyngitis resolves in less than one week 1, 4

When to Reassess

• Worsening symptoms after appropriate antibiotic initiation or symptoms lasting 5 days after treatment starts warrant reevaluation 2
• Consider non-GAS bacterial causes (Group C streptococcus, Fusobacterium necrophorum), infectious mononucleosis, or non-infectious etiologies like GERD or postnasal drip 5, 8
• Suspect Lemierre syndrome in adolescents and young adults with severe pharyngitis—this is rare but life-threatening and requires urgent diagnosis 1

The Bottom Line on "Going Untreated"

The question itself reflects the core misunderstanding: most adult "sore throats" are NOT strep throat and should "go untreated" with antibiotics. The real clinical challenge is identifying the small minority (5-15%) who actually have GAS pharyngitis and would benefit from antibiotics, while avoiding unnecessary treatment in the majority who have self-limited viral infections 1, 2, 3. Even when GAS is confirmed, the symptomatic benefit of antibiotics is modest—the primary value is complication prevention 1, 4.