Will adult strep throat resolve without antibiotics?

Will Adult Strep Throat Resolve Without Antibiotics?

Yes, adult strep throat will resolve without antibiotics in the vast majority of cases, with fever and constitutional symptoms disappearing spontaneously within 3-4 days and complete symptom resolution occurring in over 80% of patients by one week, regardless of antibiotic use. 1, 2

Natural Resolution Timeline

The natural course of untreated streptococcal pharyngitis follows a predictable pattern:

• Fever and constitutional symptoms resolve within 3-4 days of onset, even without antimicrobial therapy 3, 2
• Throat soreness lasts only 1-2 days longer in untreated patients compared to those receiving antibiotics 3, 1, 2
• By one week, more than 80% of patients achieve complete symptom resolution, regardless of whether antibiotics were used 1
• Sore throat symptoms are typically most severe in the first 2-3 days and gradually improve thereafter 2

Minimal Benefit of Antibiotics

The evidence demonstrates that antibiotics provide only modest symptomatic benefit:

• Antibiotics shorten symptom duration by merely 1-2 days compared to no treatment 3, 1, 2
• The number needed to treat is 6 after 3 days and 21 after 1 week to achieve symptom reduction in one additional patient 3, 1, 2
• This represents a very modest benefit that must be weighed against antibiotic side effects, impact on normal microbiota, contribution to antibiotic resistance, and unnecessary medicalization 1

Complications Are Extremely Rare in Adults

The historical justification for treating strep throat—preventing complications—is no longer compelling in developed countries:

• Acute rheumatic fever risk is extremely low in adults in developed countries today 3, 1
• Since 1985, nearly 1000 patients with pharyngitis have received placebo in clinical trials, and none developed acute rheumatic fever 4
• Acute glomerulonephritis is very rare and may occur even with antibiotic treatment, so antibiotics do not reliably prevent this complication 1, 2
• Suppurative complications like peritonsillar abscess occur in approximately 1% of untreated patients versus 0.09% of treated patients in recent trials 4

Clinical Decision-Making Algorithm

For patients with 0-2 Centor criteria:

• Do not prescribe antibiotics 1
• Offer analgesic therapy (NSAIDs or acetaminophen) 3, 2
• Reassure patients that typical pharyngitis resolves in less than one week 3, 1

For patients with 2-3 Centor criteria:

• Perform rapid antigen detection test (RADT) 3, 5
• Only treat if RADT is positive 3, 5
• Negative RADT does not require confirmatory throat culture in adults 3

For patients with 3-4 Centor criteria:

• Perform RADT or throat culture 1, 5
• If positive for Group A Streptococcus, discuss the modest benefits (1-2 days symptom reduction) versus risks (side effects, resistance, microbiota disruption) with the patient 1
• Consider antibiotics for severe presentations or patients with previous rheumatic fever history 1, 2

Important Caveats

• Only 5-15% of adult pharyngitis cases are actually caused by Group A Streptococcus, yet more than 60% of adults with sore throat receive antibiotics, representing massive overtreatment 3
• The large majority of adult pharyngitis cases are viral and self-limited, requiring only supportive care 5
• Delayed antibiotic strategy (starting antibiotics only after 48 hours if symptoms don't improve) reduces antibiotic use by approximately 85% without increasing risk of serious complications 4
• Patients with severe symptoms, signs of locoregional suppuration, or high local incidence of rheumatic fever warrant consideration of immediate antibiotic therapy 2, 4

Symptomatic Management

Every adult with pharyngitis should receive appropriate symptomatic care:

• NSAIDs or acetaminophen for pain and fever relief 3, 2
• Throat lozenges and salt water gargles for temporary relief 3, 2
• Reassurance that symptoms will resolve within one week 3, 1