What is the treatment for someone presenting with strep throat symptoms?

Management of Strep Throat Symptoms

For patients presenting with symptoms suggestive of strep throat, confirm the diagnosis with rapid antigen detection test (RADT) or throat culture before initiating antibiotics, then treat confirmed cases with penicillin or amoxicillin for 10 days. 1

Diagnostic Approach

Laboratory confirmation is mandatory because clinical symptoms of group A streptococcal (GAS) pharyngitis and viral pharyngitis overlap extensively. 1, 2

Clinical Features Suggesting Bacterial Infection

• Fever ≥38.0°C (100.4°F) 1, 3
• Tonsillar exudates 1, 3
• Tender anterior cervical lymphadenopathy 1, 3
• Absence of cough (cough suggests viral etiology) 1, 3

Testing Strategy

• Adults: A negative RADT is sufficient to rule out streptococcal pharyngitis without confirmatory throat culture 1, 2
• Children and adolescents: Confirm all negative RADTs with throat culture due to higher prevalence of GAS infection and risk of rheumatic fever 1, 2
• Children under 3 years: Do not routinely test, as GAS pharyngitis and rheumatic fever are rare in this age group 2
• RADT sensitivity is 80-90% compared to throat culture, meaning 10-20% of true infections may be missed 4
• RADT specificity is ≥95%, making false positives rare 4

Treatment for Confirmed GAS Pharyngitis

First-Line Therapy (No Penicillin Allergy)

• Oral penicillin V: Children 250 mg 2-3 times daily; Adolescents/adults 250 mg 3-4 times daily or 500 mg twice daily for 10 days 1, 2
• Amoxicillin: 50 mg/kg/day once daily (maximum 1000 mg) for 10 days—offers improved adherence with once-daily dosing 2
• Intramuscular benzathine penicillin G: Single dose of 600,000 U for patients <27 kg or 1,200,000 U for patients ≥27 kg—use when oral compliance is questionable 1, 2

The 10-day duration is essential for maximal pharyngeal eradication of GAS and prevention of acute rheumatic fever. 1, 5 Therapy can be safely postponed up to 9 days after symptom onset and still prevent rheumatic fever. 1

Penicillin Allergy Treatment Algorithm

For non-anaphylactic penicillin allergy:

• First-generation cephalosporins (cephalexin 20 mg/kg per dose twice daily or cefadroxil 30 mg/kg once daily) for 10 days 1, 6, 2
• These have strong, high-quality evidence for efficacy 6

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

• Clindamycin (preferred): 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 6, 2
  • Clindamycin resistance is approximately 1% in the United States 6
  • Highly effective even in chronic carriers 6
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 6, 2, 7
  • Only antibiotic requiring just 5 days due to prolonged tissue half-life 6, 2
  • Macrolide resistance is 5-8% in the United States 6, 7
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 6, 2

Up to 10% of patients with immediate hypersensitivity to penicillin have cross-reactivity with first-generation cephalosporins, so these should be avoided in anaphylactic reactions. 6

Treatment for Viral (Strep-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing. 1, 4, 2 Most pharyngitis cases are viral and self-limited, with fever and constitutional symptoms resolving spontaneously within 3-4 days. 1

Symptomatic Management

• Ibuprofen or acetaminophen for moderate to severe symptoms or high fever 1, 6, 2
• NSAIDs (ibuprofen) provide superior pain relief compared to acetaminophen 2
• Avoid aspirin in children due to Reye syndrome risk 6, 2
• Throat lozenges and warm salt water gargles can provide relief 1, 2
• Do not use corticosteroids—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects 2

Critical Pitfalls to Avoid

• Never treat based on clinical symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse, with 70% of sore throat patients receiving unnecessary antibiotics 1, 2
• Do not shorten the 10-day course (except azithromycin's 5-day regimen)—this increases treatment failure rates and risk of acute rheumatic fever 6, 2
• Do not perform routine follow-up throat cultures in asymptomatic patients who completed therapy—most are chronic carriers, not treatment failures 1, 2
• Do not test or treat asymptomatic household contacts—up to one-third of households include asymptomatic GAS carriers who don't require treatment 4, 2
• Do not use trimethoprim-sulfamethoxazole, tetracyclines, or ciprofloxacin for strep throat—these have high resistance rates or inadequate GAS activity 6, 2

Special Considerations

• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 2
• Antibiotics shorten sore throat duration by only 1-2 days, with number needed to treat of 6 at 3 days and 21 at 1 week 1
• The primary goal of antibiotic treatment is preventing acute rheumatic fever, not just symptom relief 2
• For patients with recurrent symptoms shortly after completing therapy, consider chronic GAS carrier status with intercurrent viral infections rather than true recurrent GAS pharyngitis 1, 2
• Throat cultures should be performed routinely for patients with histories of rheumatic fever 1