What is the recommended treatment for a patient with suspected streptococcal pharyngitis (strep throat) presenting with a sore throat, chills, nausea, vomiting, and swollen red tonsils, with a recent sick contact and no improvement in symptoms?

Treatment Recommendation for Suspected Streptococcal Pharyngitis

This patient requires diagnostic confirmation with a rapid antigen detection test (RADT) before initiating antibiotic therapy, and if positive, should be treated with penicillin V 500 mg twice daily or amoxicillin 1000 mg once daily for 10 days. 1

Diagnostic Approach

Confirm the diagnosis before treating. The clinical presentation (sore throat, swollen red tonsils, chills, nausea/vomiting, sick contact) is suggestive but not definitive for Group A Streptococcal (GAS) pharyngitis. 1, 2

Clinical Decision Making

• This patient has multiple Centor criteria present: tonsillar exudates/swelling, absence of cough, and likely tender anterior cervical lymphadenopathy (reported as "bilateral neck pain"). 1, 3
• The absence of documented fever is notable, though the patient reports chills, which may indicate fever that wasn't measured. 4
• Perform a RADT at this visit - patients with 2-3 Centor criteria should undergo rapid testing rather than empiric treatment. 1, 2, 3

Important Diagnostic Considerations

• A negative RADT in adults is sufficient to rule out streptococcal pharyngitis without backup throat culture, as RADT specificity is ≥95%. 1, 2
• The sick contact's telehealth diagnosis and worsening despite antibiotics raises concern about either incorrect initial diagnosis, treatment failure, or a different pathogen. 1
• Do not treat empirically without testing - up to 70% of patients with sore throat receive unnecessary antibiotics, while only 20-30% actually have GAS pharyngitis. 2

First-Line Antibiotic Treatment (If RADT Positive)

Penicillin or amoxicillin remains the treatment of choice based on proven efficacy, safety, narrow spectrum, absence of resistance, and low cost. 1, 2

Preferred Regimens

• Penicillin V: 500 mg orally twice daily for 10 days (or 250 mg three to four times daily). 1, 2
• Amoxicillin: 1000 mg once daily for 10 days (enhances adherence with once-daily dosing). 1
• Benzathine penicillin G: Single intramuscular dose of 1.2 million units if compliance with oral therapy is questionable. 1

Critical Treatment Points

• The full 10-day course is essential for bacterial eradication and prevention of complications, including rheumatic fever and post-streptococcal glomerulonephritis. 1, 5, 6
• Penicillin-resistant GAS has never been documented, making penicillin the most reliable choice. 1
• Patients typically show clinical response within 24-48 hours of appropriate therapy. 1, 7

Alternative Regimens for Penicillin Allergy

Non-Anaphylactic Allergy

• First-generation cephalosporins (cephalexin or cefadroxil) for 10 days - cross-reactivity risk is <3%. 1, 8
• Narrow-spectrum cephalosporins are strongly preferred over broad-spectrum agents to minimize antibiotic resistance. 1

Anaphylactic Allergy

• Clindamycin: 600 mg/day in 2-4 divided doses for 10 days (resistance rate ~1% in the United States). 1, 8
• Azithromycin: 500 mg on day 1, then 250 mg daily for days 2-5, though macrolide resistance rates are 5-8% in most U.S. areas. 1, 9
• Clarithromycin: 10 days of therapy may be more effective than 5 days of azithromycin for GAS eradication. 1

Antibiotics to Avoid

• Do not use tetracyclines (high resistance), sulfonamides, trimethoprim-sulfamethoxazole (do not eradicate GAS), or older fluoroquinolones like ciprofloxacin (limited activity). 1

Symptomatic Management

• Acetaminophen or NSAIDs for moderate to severe throat pain and fever control - NSAIDs are more effective than acetaminophen for pain and fever. 1, 2, 4
• Avoid aspirin due to risk of Reye syndrome if viral etiology is present. 1, 2
• Medicated throat lozenges used every 2 hours can provide additional symptom relief. 4
• Corticosteroids are not recommended for routine symptomatic management - they provide only minimal benefit. 2, 4

Management of the Sick Contact Situation

Key Considerations

• The relative's worsening despite antibiotics suggests either treatment failure, non-compliance, incorrect diagnosis, or a different pathogen. 1
• Do not treat this patient prophylactically - asymptomatic household contacts should not be tested or treated routinely. 1, 2
• If the relative had true GAS pharyngitis and is worsening on antibiotics, consider whether they completed the full course or if compliance was adequate. 1

Follow-Up and Red Flags

• Patients should improve within 24-48 hours of starting appropriate antibiotics. 1, 7
• Reevaluate if symptoms worsen after antibiotic initiation or persist beyond 5 days of treatment. 10
• No routine post-treatment testing is needed for asymptomatic patients who completed therapy. 1, 2, 8
• Watch for suppurative complications such as peritonsillar abscess, especially given the nausea and vomiting. 1

Common Pitfalls to Avoid

• Treating without diagnostic confirmation leads to massive antibiotic overuse - only 10% of adults with sore throat have GAS pharyngitis. 1, 2, 3
• Shortening treatment duration below 10 days reduces eradication rates and increases risk of complications. 1, 5
• Using broad-spectrum antibiotics when narrow-spectrum options are appropriate promotes antibiotic resistance. 1
• Testing or treating asymptomatic contacts is not indicated and wastes resources. 1, 2