What is the treatment for pharyngitis?

Treatment of Pharyngitis

Antibiotics should only be prescribed for confirmed Group A Streptococcal (GAS) pharyngitis, with penicillin or amoxicillin as first-line therapy for 10 days; the majority of pharyngitis cases are viral and require only symptomatic treatment. 1, 2

Diagnostic Approach: Confirm Before Treating

The critical first step is determining whether pharyngitis is bacterial or viral, as clinical symptoms alone cannot reliably distinguish between them. 1, 2

Testing strategy:

• Use rapid antigen detection test (RADT) or throat culture in patients with clinical features suggesting bacterial infection 2
• 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 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

Clinical screening criteria (Modified Centor):

• History of fever 3, 4
• Tonsillar exudates 3, 4
• Tender anterior cervical lymphadenopathy 3, 4
• Absence of cough 3, 4

Do not test or treat patients with 0-1 criteria, as bacterial infection is unlikely. 3, 4

Treatment Algorithm for Confirmed GAS Pharyngitis

First-Line Treatment (No Penicillin Allergy)

Penicillin or amoxicillin remains the drug of choice based on proven efficacy, safety, narrow spectrum, and low cost. 1, 5

Oral options:

• Penicillin V for 10 days 1, 5
• Amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days—preferred in children due to better taste and once-daily dosing 1, 2

Intramuscular option:

• 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

The full 10-day course is essential to achieve maximal pharyngeal eradication and prevent acute rheumatic fever. 1, 2

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy:

• First-generation cephalosporins (cephalexin 20 mg/kg twice daily or cefadroxil 30 mg/kg once daily) for 10 days 1, 6, 2

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

• Clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days—preferred due to ~1% resistance rate 1, 6, 2
• Clarithromycin 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1, 6
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 6, 7

Critical caveat: Up to 10% of patients with immediate hypersensitivity to penicillin may have cross-reactivity with first-generation cephalosporins and should avoid their use. 6

Macrolide resistance: Approximately 5-8% of GAS isolates in the United States show macrolide resistance, making clindamycin a more reliable option in areas with high resistance rates. 6

Treatment for Viral (Strep-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing. 2, 8

Symptomatic treatment:

• Ibuprofen or acetaminophen for moderate to severe symptoms or high fever—NSAIDs provide superior pain relief compared to acetaminophen 2, 9
• Avoid aspirin in children due to Reye syndrome risk 1, 2
• Warm salt water gargles can provide relief 2
• Medicated throat lozenges used every two hours are effective 9

Do not use corticosteroids as adjunctive therapy—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects. 2, 9

Common Pitfalls to Avoid

Never treat based on clinical symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse, as most pharyngitis is viral. 1, 2, 8

Do not use these antibiotics for GAS pharyngitis:

• Tetracyclines (high resistance rates) 1
• Sulfonamides or trimethoprim-sulfamethoxazole (do not eradicate GAS) 1, 2
• Older fluoroquinolones like ciprofloxacin (limited GAS activity) 1, 2

Do not shorten the antibiotic course below 10 days (except azithromycin's 5-day regimen)—even a few days less results in appreciable increases in treatment failure rates and risk of acute rheumatic fever. 1, 6

Do not perform routine follow-up throat cultures after completing therapy in asymptomatic patients. 1, 2

Do not test or treat asymptomatic household contacts. 1, 2

Special Circumstances and Treatment Failures

If symptoms persist or recur shortly after completing therapy, consider that the patient may be a chronic GAS carrier experiencing viral infections rather than true recurrent GAS pharyngitis. 2

For symptomatic treatment failures, consider:

• Clindamycin (particularly effective in chronic carriers) 6, 2
• Amoxicillin-clavulanate 2
• Narrow-spectrum cephalosporin 2
• Intramuscular benzathine penicillin G if oral compliance is questionable 2

Do not routinely identify or treat chronic GAS carriers—they are at little risk for complications or spreading infection. 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

Key Clinical Points

Patients become non-contagious after 24 hours of appropriate antibiotic therapy. 2

The primary goal of antibiotic treatment is preventing acute rheumatic fever, not just symptom relief—this is why the full 10-day course is non-negotiable for most antibiotics. 1, 2

Therapy can be safely postponed up to 9 days after symptom onset and still prevent acute rheumatic fever. 6

Group C and Group G streptococcal pharyngitis do not cause rheumatic fever and do not require the same treatment approach. 2