What is the treatment for pharyngitis?

Treatment of Pharyngitis

Penicillin V or amoxicillin for 10 days is the first-line treatment for confirmed Group A Streptococcal (GAS) pharyngitis, while viral pharyngitis requires only symptomatic management without antibiotics. 1, 2

Diagnostic Approach: Test Before Treating

The critical first step is determining whether pharyngitis is bacterial or viral, as most cases (85-90% in adults) are viral and do not benefit from antibiotics 3, 4:

• Use the modified Centor criteria to assess likelihood of GAS infection: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 2, 5
• Patients with 0-1 criteria: Do not test or treat—risk of GAS is too low 2, 3
• Patients with 2-3 criteria: Perform rapid antigen detection test (RADT) and treat only if positive 2, 3
• Patients with 4 criteria: Either test with RADT or treat empirically (both approaches acceptable) 2, 3
• In children, confirm negative RADT with throat culture due to higher rheumatic fever risk; in adults, negative RADT alone is sufficient 6, 7
• Do not routinely test children under 3 years as GAS pharyngitis and rheumatic fever are rare in this age group 6

First-Line Antibiotic Treatment for Confirmed GAS Pharyngitis

For patients without penicillin allergy:

• Penicillin V for 10 days remains the gold standard due to proven efficacy, narrow spectrum, safety, and low cost 1, 2
• Amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days is equally effective and often preferred in children due to better palatability and once-daily dosing that improves adherence 1, 2
• Intramuscular benzathine penicillin G (single dose: 600,000 units for <27 kg; 1,200,000 units for ≥27 kg) for patients unlikely to complete oral therapy 6, 8
• The full 10-day course is essential to achieve maximal pharyngeal eradication and prevent acute rheumatic fever—shortening by even a few days significantly increases treatment failure 1

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy:

• First-generation cephalosporins for 10 days (cephalexin 20 mg/kg twice daily or cefadroxil 30 mg/kg once daily) are the preferred alternatives with strong evidence 1, 2, 9
• Cross-reactivity risk is only 0.1% in patients with non-immediate reactions 9

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

• Clindamycin 7 mg/kg three times daily (maximum 300 mg/dose) for 10 days is the preferred choice with ~1% resistance rate in the US 1, 2, 9
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days is acceptable but has 5-8% macrolide resistance in the US 1, 2, 9
• Clarithromycin 7.5 mg/kg twice daily (maximum 250 mg/dose) for 10 days is also acceptable with similar resistance concerns 1, 9
• Up to 10% cross-reactivity exists between penicillin and cephalosporins in patients with immediate hypersensitivity, making all beta-lactams unsafe 1, 9

Treatment for Viral (Strep-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing 6, 3:

• NSAIDs (ibuprofen) or acetaminophen for moderate to severe symptoms or fever—NSAIDs provide superior pain relief compared to acetaminophen 6, 5
• Avoid aspirin in children due to Reye syndrome risk 6, 5
• Medicated throat lozenges every 2 hours can provide symptom relief 5
• Do not use corticosteroids routinely—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects 6, 5

Critical Pitfalls to Avoid

• Never treat based on clinical symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse as most pharyngitis is viral 2, 6
• Do not use tetracyclines (high resistance), sulfonamides or trimethoprim-sulfamethoxazole (do not eradicate GAS), or older fluoroquinolones like ciprofloxacin (limited GAS activity) 1, 6
• Do not perform routine follow-up throat cultures after completing therapy in asymptomatic patients 1, 6
• Do not test or treat asymptomatic household contacts 1, 6
• Do not shorten antibiotic courses below 10 days (except azithromycin's 5-day regimen)—this dramatically increases treatment failure and rheumatic fever risk 1, 9
• Avoid broad-spectrum antibiotics when narrow-spectrum options are effective—this unnecessarily increases resistance and cost 1, 2

Special Considerations

• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 6
• The primary goal is preventing acute rheumatic fever, not just symptom relief—antibiotics shorten symptoms by only 1-2 days 2, 6
• For recurrent symptoms shortly after treatment, consider that the patient may be a chronic GAS carrier experiencing viral infections rather than true recurrent GAS pharyngitis 6
• Chronic carriers generally do not require treatment as they are at little risk for complications or spreading infection 6
• Treatment can be safely delayed up to 9 days after symptom onset and still prevent acute rheumatic fever 9