What is the treatment for pharyngitis?

Treatment of Pharyngitis

For confirmed Group A Streptococcal (GAS) pharyngitis, treat with penicillin V or amoxicillin for 10 days; for viral pharyngitis (negative testing), withhold antibiotics entirely and provide symptomatic care only. 1, 2

Diagnostic Approach: Test Before Treating

• Do not treat based on clinical symptoms alone—laboratory confirmation is mandatory because viral and bacterial pharyngitis overlap extensively 2, 3
• Use the modified Centor criteria to determine who needs testing: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 4
• Patients with 0-1 Centor criteria: Do not test or treat—viral etiology is most likely 1, 4
• Patients with 2-4 Centor criteria: Perform rapid antigen detection test (RADT) 1, 4
• In adults: A negative RADT is sufficient to rule out GAS without confirmatory culture 2, 5
• In children: Confirm negative RADT with throat culture due to higher prevalence and rheumatic fever risk 2, 5
• Children under 3 years: Do not routinely test—GAS pharyngitis and acute rheumatic fever are rare in this age group 1, 2

Treatment Algorithm for Confirmed GAS Pharyngitis

First-Line Treatment (No Penicillin Allergy)

• Penicillin V for 10 days OR amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days 1, 2, 6
• Amoxicillin offers superior adherence with once-daily dosing and better palatability in children 1, 2
• The full 10-day course is essential to achieve maximal pharyngeal eradication and prevent acute rheumatic fever 1, 2
• 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 2

Penicillin-Allergic Patients

For non-anaphylactic/non-immediate penicillin allergy:

• First-generation cephalosporins (cephalexin 20 mg/kg twice daily or cefadroxil 30 mg/kg once daily) for 10 days 1, 7, 2

For immediate/anaphylactic penicillin allergy (avoid all beta-lactams):

• Clindamycin 7 mg/kg three times daily (maximum 300 mg/dose) for 10 days (preferred—only ~1% resistance in US) 1, 7, 2
• Clarithromycin 7.5 mg/kg twice daily (maximum 250 mg/dose) for 10 days 1, 7
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 7, 8

Critical caveat: Up to 10% cross-reactivity exists between penicillin and first-generation cephalosporins in patients with immediate hypersensitivity—avoid cephalosporins entirely in these patients 7, 2

Macrolide Resistance Considerations

• Macrolide resistance among GAS ranges from 5-8% in the United States but varies geographically 7, 2
• Clindamycin is preferred over macrolides in areas with high macrolide resistance due to its superior efficacy and minimal resistance (~1%) 7, 2
• Azithromycin requires only 5 days due to prolonged tissue half-life, unlike other antibiotics requiring 10 days 1, 7, 8

Treatment for Viral (Strep-Negative) Pharyngitis

• Withhold antibiotics entirely for patients with negative GAS testing 2, 3
• NSAIDs (ibuprofen) provide superior pain relief compared to acetaminophen in randomized controlled trials 2, 9
• Acetaminophen or ibuprofen for moderate to severe symptoms or high fever 1, 2
• Avoid aspirin in children due to Reye syndrome risk 1, 2
• Medicated throat lozenges every 2 hours can provide relief 9
• Do not use corticosteroids—they provide only minimal benefit (~5 hours pain reduction) with potential adverse effects 2, 9

Critical Pitfalls to Avoid

• Never treat without laboratory confirmation—this leads to massive antibiotic overuse since most pharyngitis is viral 2, 3
• Do not use tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, or ciprofloxacin—high resistance rates or inadequate GAS coverage 2
• Do not perform routine follow-up throat cultures after completing therapy in asymptomatic patients 1, 2
• Do not test or treat asymptomatic household contacts of patients with GAS pharyngitis 1
• Do not prescribe shorter courses than recommended (except azithromycin's 5-day regimen)—this leads to treatment failure and complications 7, 2
• Do not assume all penicillin-allergic patients cannot receive cephalosporins—only those with immediate/anaphylactic reactions should avoid them 7, 2

Special Circumstances

Recurrent Pharyngitis

• Consider that the patient may be a chronic GAS carrier experiencing repeated viral infections rather than true recurrent GAS pharyngitis 1, 2
• Chronic carriers generally do not require treatment—they are unlikely to spread infection or develop complications 1, 2
• Treatment of carriers is justified only in special circumstances: community outbreak of rheumatic fever, family history of rheumatic fever, or excessive family anxiety 2

Treatment Failures

• For symptomatic treatment failures, consider clindamycin, amoxicillin-clavulanate, or narrow-spectrum cephalosporin—these achieve higher eradication rates 2
• Intramuscular benzathine penicillin G if oral compliance is questionable 2

Key Clinical Points

• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 2
• Primary goal of antibiotic treatment is preventing acute rheumatic fever, not just symptom relief 2, 3
• Antibiotics shorten symptom duration by only 1-2 days but prevent suppurative complications like peritonsillar abscess 3, 10
• Group C and Group G streptococcal pharyngitis do not cause rheumatic fever and do not require the same treatment approach 2