What are the symptoms and treatment for strep throat?

Symptoms and Treatment of Strep Throat

Clinical Symptoms of Streptococcal Pharyngitis

The hallmark symptoms of strep throat include sudden onset of severe sore throat, fever above 100.4°F (38°C), tonsillar exudates (white patches on tonsils), and tender, enlarged anterior cervical lymph nodes. 1, 2, 3

Key symptoms that suggest strep throat:

• Abrupt symptom onset with intense throat pain 3
• Fever, chills, and malaise 3
• Headache 3
• Tonsillar or pharyngeal exudate (pus on tonsils or back of throat) 2, 3
• Tender, swollen lymph nodes in the front of the neck 2, 3

Importantly, symptoms that suggest viral pharyngitis (NOT strep) include cough, runny nose (coryza), conjunctivitis (pink eye), and diarrhea—these are uncommon with strep throat. 2, 3

Diagnostic Testing Required

You cannot diagnose strep throat based on symptoms alone—laboratory confirmation is mandatory because viral and streptococcal pharyngitis symptoms overlap extensively. 1, 4

• Use a rapid antigen detection test (RADT) or throat culture to confirm the diagnosis 1, 4
• In adults, a negative RADT is sufficient to rule out strep without confirmatory culture 4
• In children, confirm all negative RADTs with throat culture due to higher rheumatic fever risk 4
• Throat culture remains the gold standard despite the 1-2 day delay in results 2, 3

Treatment Algorithm

For Patients WITHOUT Penicillin Allergy

Penicillin V or amoxicillin for 10 days is the standard of care and remains the treatment of choice due to proven efficacy, narrow spectrum, safety, and low cost. 1, 5, 4, 6

Specific dosing:

• Amoxicillin: 50 mg/kg/day once daily (maximum 1000 mg) for 10 days offers improved adherence with once-daily dosing 4
• Penicillin V: 250 mg twice daily for 10 days for children 7
• Intramuscular benzathine penicillin G: 600,000 units for patients <27 kg; 1,200,000 units for ≥27 kg as a single dose for patients unlikely to complete oral therapy 4, 6

For Patients WITH Penicillin Allergy

First, determine if the allergy is immediate/anaphylactic (hives, angioedema, respiratory distress within 1 hour) or non-immediate (delayed rash). 5

For non-immediate penicillin allergy:

• First-generation cephalosporins are preferred (cephalexin 20 mg/kg per dose twice daily or cefadroxil 30 mg/kg once daily for 10 days) 5, 4
• Cross-reactivity risk is only 0.1% with non-severe delayed reactions 5

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

• Clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days is the preferred choice with only ~1% resistance in the US 1, 5, 4
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days is acceptable but has 5-8% macrolide resistance 5, 4
• Clarithromycin 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days is also acceptable 5, 4

Critical Treatment Duration

A full 10-day course is essential for all antibiotics except azithromycin to achieve maximal pharyngeal eradication and prevent acute rheumatic fever. 1, 5, 4, 8

• Therapy can be safely postponed up to 9 days after symptom onset and still prevent rheumatic fever 1
• Azithromycin requires only 5 days due to its prolonged tissue half-life 5, 4
• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 4

Symptomatic Treatment

For viral pharyngitis (negative strep test), withhold antibiotics entirely. 4

• Ibuprofen or acetaminophen for moderate to severe symptoms or high fever 4
• NSAIDs (ibuprofen) provide superior pain relief compared to acetaminophen 4
• Avoid aspirin in children due to Reye syndrome risk 4, 8
• Warm salt water gargles can provide relief 4

Common Pitfalls to Avoid

• Never treat based on symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse 4
• Do not use tetracyclines, sulfonamides, trimethoprim-sulfamethoxazole, or ciprofloxacin for strep throat 4
• Do not perform routine follow-up throat cultures after completing therapy in asymptomatic patients 1, 4
• Do not shorten the treatment course below 10 days (except azithromycin's 5-day regimen) despite clinical improvement 5, 4
• Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions due to up to 10% cross-reactivity 1, 5
• Do not use corticosteroids as adjunctive therapy—they provide only minimal benefit with potential adverse effects 4

Special Circumstances

If symptoms persist or recur shortly after completing therapy, the patient may be a chronic strep carrier experiencing viral infections rather than true recurrent strep pharyngitis. 1, 4

• Chronic carriers generally do not require treatment as they are at little risk for complications or spreading infection 1, 4
• Treatment of carriers is justified only in special circumstances: community outbreak of rheumatic fever, family history of rheumatic fever, or excessive family anxiety 1