What is the treatment approach for a patient with a sore throat and bleeding, but a negative streptococcal (strep) test result?

Sore Throat with Bleeding and Negative Strep Test

Do not prescribe antibiotics for this patient—the negative strep test rules out group A streptococcal pharyngitis, and antibiotics are not indicated regardless of bleeding symptoms. 1

Immediate Assessment for Bleeding

The presence of bleeding with pharyngitis requires urgent evaluation to exclude serious causes that are unrelated to typical infectious pharyngitis:

• Examine for peritonsillar abscess, retropharyngeal abscess, or other suppurative complications that can cause bleeding and require immediate intervention 2
• Assess for trauma, foreign body, or malignancy if bleeding is significant or persistent
• Evaluate for coagulopathy or anticoagulant use that may explain bleeding with otherwise typical pharyngitis

Diagnostic Interpretation

A negative strep test is sufficient to rule out group A streptococcal pharyngitis in adults, and no further microbiological testing is needed. 1

• The specificity of rapid antigen detection tests (RADTs) is ≥95%, making false positives rare 1
• In adults, a negative RADT alone is adequate without backup throat culture, given the low prevalence (5-10%) of streptococcal pharyngitis and extremely low risk of acute rheumatic fever 1
• In children and adolescents, a negative RADT should be confirmed with throat culture before making final treatment decisions, as the sensitivity of RADTs is only 80-90% 2

Treatment Approach

Provide symptomatic treatment only—most cases are viral and self-limiting. 1

Symptomatic Management

• Ibuprofen or acetaminophen (paracetamol) for pain relief are recommended with moderate strength of evidence 1
• Throat lozenges and reassurance that symptoms typically resolve in less than 1 week 1
• Antibiotics shorten sore throat duration by only 1-2 days, with a number needed to treat of 6 at 3 days and 21 at 1 week 1

Antibiotic Avoidance

• Withhold or discontinue antimicrobial therapy for patients with negative strep tests 1
• Up to 70% of patients with sore throats receive unnecessary antibiotic prescriptions, while only 20-30% actually have group A streptococcal pharyngitis 1
• Treating based on clinical symptoms alone without laboratory confirmation leads to overuse of antibiotics 1

Special Considerations for Bleeding

If bleeding is more than minor spotting or blood-tinged saliva:

• Consider alternative diagnoses including infectious mononucleosis (which can cause tonsillar hemorrhage), diphtheria (rare but serious), or non-infectious causes 3
• Refer urgently if bleeding is significant, as this suggests a complication beyond typical viral pharyngitis
• Minor bleeding or blood-streaked mucus can occur with severe viral pharyngitis due to mucosal inflammation and does not change management if strep is negative

Pediatric-Specific Guidance

For children with negative RADT, send a backup throat culture before deciding on treatment. 1

• Treatment within 9 days of symptom onset still effectively prevents acute rheumatic fever, so waiting for culture results is safe 1
• The prevalence of group A streptococcal pharyngitis in children ages 5-15 is 20-30%, making confirmation necessary 1
• Do not test or treat asymptomatic household contacts—up to one-third of households include asymptomatic carriers, and prophylaxis has not been shown to reduce subsequent infections 1

Common Pitfalls to Avoid

• Do not switch antibiotics without microbiological indication, as this increases risk of adverse effects without clinical benefit 1
• Do not prescribe antibiotics "just in case" for bleeding—the negative strep test is definitive, and antibiotics do not prevent post-streptococcal glomerulonephritis 1
• Do not assume bleeding indicates bacterial infection—viral pharyngitis can cause mucosal friability and minor bleeding 3