What is the treatment for pharyngitis?

Treatment of Pharyngitis

For confirmed Group A Streptococcal (GAS) pharyngitis, penicillin V or amoxicillin for 10 days is the treatment of choice; for viral pharyngitis (negative testing), antibiotics should be withheld entirely and only symptomatic treatment provided. 1, 2

Diagnostic Approach: Test Before Treating

The critical first step is determining whether pharyngitis is bacterial or viral, as most cases (85-90% in adults, 70-85% in children) are viral and do not benefit from antibiotics 3, 4, 5:

• Use clinical screening first: Apply the Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) to determine who needs testing 2, 3
• Do not test or treat patients with 0-1 Centor criteria—they are unlikely to have GAS 3, 4
• Test patients with 2-4 Centor criteria using rapid antigen detection test (RADT) 1, 2, 3
• In children, confirm negative RADT with throat culture due to higher prevalence of GAS and rheumatic fever risk 1, 2
• In adults, negative RADT is sufficient without confirmatory culture when test sensitivity exceeds 80% 1, 3, 4
• Do not routinely test children under 3 years old, as GAS pharyngitis and rheumatic fever are rare in this age group 1, 2

The specificity of RADT exceeds 95% with sensitivity ≥90%, making positive results reliable for diagnosis without culture confirmation 1, 6.

Treatment for Confirmed GAS Pharyngitis

First-Line Antibiotics (Non-Allergic Patients)

Penicillin or amoxicillin remains the gold standard based on proven efficacy, narrow spectrum, safety, and low cost 1, 2, 7:

• Penicillin V: Standard dosing for 10 days 1, 8, 3
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days—preferred in children due to better palatability and once-daily dosing that enhances adherence 1, 2, 7
• Intramuscular benzathine penicillin G: Single dose (600,000 U for <27 kg; 1,200,000 U for ≥27 kg) for patients unlikely to complete oral therapy 1, 2

The full 10-day course is essential—shortening by even a few days significantly increases treatment failure rates and risk of acute rheumatic fever 1, 2. GAS has never developed resistance to penicillin 1.

Penicillin-Allergic Patients: Algorithm Based on Allergy Type

The treatment approach depends critically on whether the allergy is immediate/anaphylactic or non-immediate 1, 9, 2:

For non-anaphylactic penicillin allergy:

• First-generation cephalosporins (cephalexin 20 mg/kg twice daily or cefadroxil 30 mg/kg once daily) for 10 days are preferred first-line alternatives 1, 9, 2
• These have strong, high-quality evidence for efficacy 9

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

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg/dose) for 10 days—preferred due to ~1% resistance rate in the US and high efficacy even in chronic carriers 1, 9, 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days—only antibiotic approved for shortened course due to prolonged tissue half-life 1, 9, 10
• Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg/dose) for 10 days 1, 9

Critical caveat: Up to 10% of patients with immediate penicillin hypersensitivity have cross-reactivity with first-generation cephalosporins, so these must be avoided in anaphylactic reactions 1, 9.

Macrolide Resistance Considerations

Macrolide resistance among GAS varies geographically but averages 5-8% in the United States 1, 9. Clindamycin resistance remains very low at approximately 1%, making it more reliable than macrolides in areas with high resistance 9, 2.

Treatment for Viral (GAS-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing—antibiotics provide no benefit and contribute to resistance 2, 7, 3:

• NSAIDs (ibuprofen) provide superior pain relief compared to acetaminophen in randomized trials 2, 5
• Acetaminophen is an alternative for moderate to severe symptoms or high fever 1, 2, 7
• Avoid aspirin in children due to Reye syndrome risk 1, 9, 2
• Medicated throat lozenges used every 2 hours are effective 5
• Warm salt water gargles can provide relief 2

Do not use corticosteroids as adjunctive therapy—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects 2, 5.

Critical Pitfalls to Avoid

• Never treat based on clinical symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse since 85-90% of adult pharyngitis is viral 2, 7, 3
• Do not use tetracyclines (high resistance), sulfonamides or trimethoprim-sulfamethoxazole (do not eradicate GAS), or older fluoroquinolones like ciprofloxacin (limited GAS activity) 1, 9, 2
• Do not prescribe shorter courses than recommended (except azithromycin's 5-day regimen)—this increases treatment failure and rheumatic fever risk 1, 9
• Do not assume all penicillin-allergic patients cannot receive cephalosporins—only those with immediate/anaphylactic reactions should avoid them 9
• Do not perform routine follow-up throat cultures after completing therapy in asymptomatic patients 1, 2, 7
• Do not test or treat asymptomatic household contacts 1, 2

Special Circumstances

For recurrent pharyngitis shortly after treatment:

• Consider that the patient may be a chronic GAS carrier experiencing viral infections rather than true recurrent GAS pharyngitis 2
• Chronic carriers generally do not require treatment as they are at little risk for complications or spreading infection 2
• For true treatment failures, consider clindamycin, amoxicillin-clavulanate, or intramuscular benzathine penicillin G 2

Primary goal of treatment: The main objective is preventing acute rheumatic fever, not just symptom relief—this requires adequate bacterial eradication with full-course therapy 1, 2. Patients become non-contagious after 24 hours of appropriate antibiotic therapy 2.