First-Line Treatment for Viral Pharyngitis
For viral pharyngitis, withhold antibiotics entirely and provide symptomatic treatment only with NSAIDs or acetaminophen for pain and fever relief. 1
Key Principle: No Antibiotics for Viral Pharyngitis
The WHO Expert Committee and Infectious Diseases Society of America explicitly endorse a strategy of watchful waiting, symptom relief, and no antibiotic treatment as the first-choice approach for viral pharyngitis. 1 Pharyngitis has predominantly a viral origin, and antibiotics provide no benefit while contributing to antimicrobial resistance. 1
Symptomatic Treatment Algorithm
Pain and Fever Management
- NSAIDs (ibuprofen) are superior to acetaminophen for pain relief and fever control in pharyngitis, based on randomized controlled trial evidence. 2, 3
- Acetaminophen is an acceptable alternative for moderate to severe symptoms or high fever. 4, 2
- Avoid aspirin in children due to Reye syndrome risk. 4, 2
Additional Symptomatic Measures
- Medicated throat lozenges used every two hours provide effective symptom relief. 3
- Warm salt water gargles can provide additional relief. 2
- Do not use corticosteroids as adjunctive therapy—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects. 2
Critical Diagnostic Requirement
Laboratory confirmation with rapid antigen detection test (RADT) or throat culture is required before any treatment decision, as clinical symptoms of viral and bacterial pharyngitis overlap broadly. 2 This prevents inappropriate antibiotic use while ensuring bacterial infections are not missed.
Testing Algorithm
- In adults, a negative RADT is sufficient to rule out streptococcal pharyngitis without confirmatory culture. 2
- In children, confirm negative RADT with throat culture due to higher prevalence of Group A Streptococcus and rheumatic fever risk. 2
- Do not test children under 3 years old routinely, as GAS pharyngitis and rheumatic fever are rare in this age group. 2
Common Pitfalls to Avoid
- Never treat based on clinical symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse. 2 The majority of pharyngitis cases are viral and do not benefit from antibiotics. 1
- Do not prescribe antibiotics "just in case" or for patient satisfaction—this contributes to antimicrobial resistance without clinical benefit. 1
- Do not use tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, or older fluoroquinolones for pharyngitis. 2
When Antibiotics ARE Indicated
Antibiotics should only be prescribed for confirmed or highly suspected bacterial pharyngitis (Group A Streptococcus), not for viral pharyngitis. 1, 2 If GAS is confirmed: