What is the treatment for pharyngitis?

Treatment of Pharyngitis

For confirmed Group A Streptococcal (GAS) pharyngitis, penicillin V or amoxicillin for 10 days is the treatment of choice; for penicillin-allergic patients with non-anaphylactic reactions, use first-generation cephalosporins, and for immediate/anaphylactic reactions, use clindamycin or azithromycin. 1, 2

Diagnostic Approach: Test Before Treating

The critical first step is confirming bacterial etiology, as most pharyngitis (85-90% in adults, 70-85% in children) is viral and does not benefit from antibiotics 1, 2.

Use the Modified Centor Criteria to guide testing: 1, 2, 3

• Fever (temperature >38°C)
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough

Testing algorithm based on Centor score: 1, 2, 4

• 0-1 criteria: No testing or antibiotics needed—viral etiology most likely
• 2-3 criteria: Perform rapid antigen detection test (RADT)
• 4 criteria: Either perform RADT or treat empirically (though testing preferred)

For adults: A negative RADT is sufficient to rule out GAS without confirmatory culture 4, 5

For children: Confirm negative RADT with throat culture due to higher prevalence of GAS and rheumatic fever risk 1, 4

Do not test children under 3 years: GAS pharyngitis and acute rheumatic fever are rare in this age group 1, 4

First-Line Antibiotic Treatment for Confirmed GAS

Penicillin V or amoxicillin for 10 days remains the gold standard due to proven efficacy in preventing acute rheumatic fever, narrow spectrum, zero documented resistance, safety profile, and low cost 1, 2, 4.

Specific dosing: 1, 2

• Penicillin V: 250 mg orally 2-3 times daily for 10 days (adults); 250 mg 2-3 times daily for children <27 kg
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days—preferred in children due to better taste and once-daily dosing that improves adherence

Alternative: Intramuscular benzathine penicillin G for patients unlikely to complete oral therapy 1, 4

• 600,000 units for patients <27 kg
• 1,200,000 units for patients ≥27 kg
• Single dose provides complete treatment

The full 10-day course is essential—shortening by even a few days increases treatment failure rates from 5-10% to 20-30% 1, 2.

Treatment for Penicillin-Allergic Patients

The type of allergic reaction determines safe alternatives, as cross-reactivity risk varies dramatically 1, 2, 6.

Non-Anaphylactic Penicillin Allergy (Delayed Rash, No Respiratory/Cardiovascular Symptoms)

First-generation cephalosporins for 10 days (cross-reactivity risk only 0.1%) 1, 2, 6:

• Cephalexin: 500 mg orally twice daily (adults); 20 mg/kg per dose twice daily (children)
• Cefadroxil: 1 gram once daily (adults); 30 mg/kg once daily (children)

Immediate/Anaphylactic Penicillin Allergy (Anaphylaxis, Angioedema, Urticaria Within 1 Hour)

Avoid all beta-lactams including cephalosporins due to up to 10% cross-reactivity risk 1, 2, 6.

Preferred alternative: Clindamycin for 10 days (only 1% resistance in US) 1, 2, 6:

• 300 mg orally three times daily (adults)
• 7 mg/kg per dose three times daily, maximum 300 mg per dose (children)
• Particularly effective in chronic carriers who failed penicillin

Acceptable alternatives: 1, 2, 6

• Azithromycin: 500 mg day 1, then 250 mg days 2-5 (adults); 12 mg/kg once daily for 5 days, maximum 500 mg (children)—only antibiotic requiring just 5 days due to prolonged tissue half-life
• Clarithromycin: 250 mg twice daily for 10 days (adults); 7.5 mg/kg per dose twice daily, maximum 250 mg per dose, for 10 days (children)

Important caveat on macrolides: Resistance rates are 5-8% in the United States and vary geographically, making clindamycin more reliable 1, 2, 6. Azithromycin also lacks data proving it prevents rheumatic fever 6.

Treatment for Viral (Strep-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing 2, 4.

Symptomatic treatment: 1, 2, 4

• NSAIDs (ibuprofen) provide superior pain relief compared to acetaminophen in randomized trials
• Acetaminophen for patients who cannot take NSAIDs
• Avoid aspirin in children due to Reye syndrome risk
• Warm salt water gargles can provide relief

Do not use corticosteroids routinely—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects 2, 4, 3.

Antibiotics That Should NEVER Be Used for GAS Pharyngitis

The following have proven ineffective or inappropriate: 1, 4

• Tetracyclines: High resistance rates
• Sulfonamides and trimethoprim-sulfamethoxazole: Do not eradicate GAS from the pharynx
• Older fluoroquinolones (ciprofloxacin): Limited activity against GAS
• Newer fluoroquinolones (levofloxacin, moxifloxacin): Unnecessarily broad spectrum and expensive despite in vitro activity

Common Pitfalls to Avoid

Never treat based on clinical symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse as 85-90% of adult pharyngitis is viral 1, 2, 4.

Do not perform routine follow-up throat cultures after completing therapy in asymptomatic patients 1, 2, 4.

Do not test or treat asymptomatic household contacts of patients with GAS pharyngitis 1, 4.

Do not assume all penicillin-allergic patients cannot receive cephalosporins—only those with immediate/anaphylactic reactions should avoid them 2, 6.

Do not prescribe shorter courses than recommended (except azithromycin's 5-day regimen)—this increases treatment failure and rheumatic fever risk 1, 2, 6.

Do not use broad-spectrum cephalosporins when narrow-spectrum first-generation agents are appropriate—they are more expensive and select for resistant flora 1, 6.

Special Circumstances: Recurrent Pharyngitis and Chronic Carriers

If symptoms persist or recur shortly after completing therapy, consider that the patient may be a chronic GAS carrier experiencing viral infections rather than true recurrent GAS 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: 4

• Community outbreak of rheumatic fever
• Family history of rheumatic fever
• Excessive family anxiety

For true treatment failures, consider clindamycin, amoxicillin-clavulanate, or narrow-spectrum cephalosporin as these achieve higher eradication rates 4.

Key Clinical Points

Patients become non-contagious after 24 hours of appropriate antibiotic therapy 4.

The primary goal of antibiotic treatment is preventing acute rheumatic fever, not just symptom relief—this is why the full 10-day course matters even though symptoms resolve in 3-4 days 1, 4.

Antibiotics shorten symptom duration by only 1-2 days but prevent suppurative complications like peritonsillar abscess and acute otitis media 2.

Therapy can be safely postponed up to 9 days after symptom onset and still prevent acute rheumatic fever, so waiting for culture results is acceptable 6.