What is the recommended treatment for pharyngitis?

Treatment of Pharyngitis

Penicillin or amoxicillin for 10 days is the first-line treatment for Group A streptococcal (GAS) pharyngitis in non-allergic patients, based on proven efficacy, narrow spectrum, safety, and low cost. 1

Diagnostic Testing Before Treatment

• Test patients with 2 or more Centor criteria (fever history, tonsillar exudates, absence of cough, tender anterior cervical lymphadenopathy) using rapid antigen detection test (RADT) or throat culture before prescribing antibiotics 1
• Do not test or treat patients with viral features such as cough, rhinorrhea, hoarseness, or oral ulcers, as these strongly suggest non-streptococcal etiology 1
• Children under 3 years generally do not require testing unless they have specific risk factors like an older sibling with GAS infection 1

First-Line Antibiotic Regimens (Non-Allergic Patients)

Oral Options

• Penicillin V: 250 mg twice daily for 10 days (adults); 250 mg 2-3 times daily for children 1
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days, or 25 mg/kg twice daily (maximum 500 mg per dose) 1
  • Amoxicillin is often preferred in young children due to better palatability and once-daily dosing improves adherence 1

Parenteral Option

• Benzathine penicillin G (intramuscular): Single dose of 600,000 units for patients <27 kg; 1,200,000 units for patients ≥27 kg 1
  • Reserved for patients unlikely to complete oral therapy due to compliance concerns 1

Treatment for Penicillin-Allergic Patients

Non-Anaphylactic/Non-Immediate Allergy

First-generation cephalosporins are the preferred alternatives with strong, high-quality evidence supporting their use 1, 2:

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg/dose) for 10 days 1, 2
• Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days 1, 2
• Cross-reactivity risk is only 0.1-3% in patients with non-immediate reactions 2

Immediate/Anaphylactic Penicillin Allergy

Avoid all beta-lactams including cephalosporins due to up to 10% cross-reactivity risk 1, 2. Use these alternatives:

• Clindamycin (preferred): 7 mg/kg per dose three times daily (maximum 300 mg/dose) for 10 days 1, 2

  • Only ~1% resistance rate in the United States 2
  • Particularly effective for chronic carriers and difficult-to-eradicate infections 2

• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 3

  • Only antibiotic approved for 5-day course due to prolonged tissue half-life 1, 2
  • Macrolide resistance is 5-8% in the United States and varies geographically 2

• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg/dose) for 10 days 1, 2

  • Similar resistance concerns as azithromycin 2

Critical Treatment Duration Requirements

A full 10-day course is essential for all antibiotics except azithromycin to achieve maximal pharyngeal eradication of GAS and prevent acute rheumatic fever 1, 2. Shortening the course even by a few days significantly increases treatment failure rates 2.

Adjunctive Symptomatic Therapy

• NSAIDs or acetaminophen should be used for moderate to severe symptoms or high fever 1, 4
• Aspirin must be avoided in children due to Reye syndrome risk 1, 2
• Corticosteroids are not recommended as they provide only minimal symptom reduction 1, 4
• Medicated throat lozenges every 2 hours can provide additional symptom relief 4

Special Circumstances

Recurrent Pharyngitis

Consider that patients may be chronic GAS carriers experiencing repeated viral infections rather than true recurrent streptococcal infections 1. For documented recurrent GAS pharyngitis:

• Clindamycin: 20-30 mg/kg/day for children or 600 mg/day in 2-4 divided doses for adults for 10 days 1, 2
• Amoxicillin/clavulanate: 40 mg/kg/day in 3 divided doses for 10 days (maximum 750 mg amoxicillin/day) 1
• Chronic carriers generally do not require treatment as they are unlikely to spread infection or develop complications 1, 2

Concurrent Infectious Mononucleosis

Avoid ampicillin and amoxicillin if mononucleosis is suspected due to high risk of rash 5, 6. Use first-generation cephalosporin, macrolide, or clindamycin instead if GAS treatment is documented 6.

Pregnancy

Penicillin or amoxicillin remains first-line with proven safety in pregnancy 5. For penicillin-allergic pregnant patients, use cephalexin/cefadroxil for non-anaphylactic allergy or clindamycin for anaphylactic allergy 5.

Post-Treatment Management

• No routine follow-up cultures or RADTs are needed for asymptomatic patients who completed therapy 1, 2
• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 5, 6
• Do not test or treat asymptomatic household contacts routinely 1

Common Pitfalls to Avoid

• Do not use tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, or older fluoroquinolones as they are ineffective against GAS 1
• Do not prescribe broad-spectrum cephalosporins (cefdinir, cefpodoxime, cefixime) when narrow-spectrum agents are appropriate, as they are more expensive and promote resistance 1, 2
• Do not assume all penicillin-allergic patients need to avoid cephalosporins - only those with immediate/anaphylactic reactions should avoid them 2
• Do not treat without microbiological confirmation in patients with equivocal clinical features, as most pharyngitis is viral 5
• Do not shorten treatment duration below 10 days (except azithromycin's 5-day course) as this increases treatment failure and rheumatic fever risk 2