What is the proper management of pharyngitis?

Proper Management of Pharyngitis

Diagnostic Approach: Test Before Treating

The cornerstone of proper pharyngitis management is laboratory confirmation before prescribing antibiotics—clinical symptoms alone cannot reliably distinguish Group A Streptococcal (GAS) pharyngitis from viral causes. 1, 2

When to Test

• Use modified Centor criteria to guide testing decisions: Test patients with ≥3 of the following: fever by history, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough 1
• Patients with <3 Centor criteria do not need testing as they have low probability of GAS infection 1
• Do NOT routinely test children <3 years old because GAS pharyngitis and acute rheumatic fever are rare in this age group 1, 2

Testing Strategy

• Rapid antigen detection test (RADT) is the first-line diagnostic tool 1, 2
• In adults: A negative RADT is sufficient to rule out streptococcal pharyngitis without confirmatory culture 1, 2
• In children: Confirm negative RADT with throat culture due to higher prevalence and rheumatic fever risk 2
• A positive RADT is diagnostic and does not require backup culture 3

Treatment of Confirmed GAS Pharyngitis

First-Line Antibiotics (Non-Penicillin Allergic)

Penicillin or amoxicillin for 10 days is the standard of care based on narrow spectrum, low cost, and proven efficacy. 1, 3

• Amoxicillin 50 mg/kg once daily (maximum 1,000 mg) for 10 days offers superior adherence with once-daily dosing 3, 2
• Penicillin V 250 mg four times daily or 500 mg twice daily for 10 days is equally effective 3
• Intramuscular benzathine penicillin G (1.2 million units as single dose) if oral adherence is a concern 3, 2

Penicillin-Allergic Patients

• For non-anaphylactic allergy: First-generation cephalosporins (e.g., cephalexin) for 10 days 1, 3, 2
• For anaphylactic/immediate allergy:
  • Clindamycin 7 mg/kg three times daily (maximum 300 mg/dose) for 10 days 2
  • Clarithromycin for 10 days 1, 2
  • Azithromycin is the ONLY antibiotic approved for a shorter 5-day course (12 mg/kg once daily for children; 500 mg day 1, then 250 mg days 2-5 for adults) 3, 4

Critical Treatment Principles

• The 10-day duration is mandatory for most antibiotics to maximize pharyngeal eradication and prevent acute rheumatic fever 3, 2
• Do NOT prescribe shorter courses of penicillin or amoxicillin as this increases treatment failure risk 3
• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 2

Treatment of Viral (Strep-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing—antibiotics do little to alleviate viral symptoms and cause unnecessary adverse effects. 1, 2

Symptomatic Management

• NSAIDs (ibuprofen) provide superior pain relief compared to acetaminophen for moderate to severe symptoms or high fever 1, 2, 5
• Acetaminophen is an acceptable alternative 1, 2
• Avoid aspirin in children due to Reye syndrome risk 1, 2
• Medicated throat lozenges used every 2 hours are effective 5
• Warm salt water gargles can provide relief 2

What NOT to Use

• Do NOT use corticosteroids as adjunctive therapy—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects 1, 2, 5

Common Pitfalls to Avoid

Testing Errors

• Never treat based on clinical symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse, as >60% of adults with sore throat receive unnecessary antibiotics 1, 2
• Do NOT perform routine follow-up throat cultures after completing therapy in asymptomatic patients 1, 2
• Do NOT test or treat asymptomatic household contacts 1, 2

Antibiotic Selection Errors

• Do NOT use tetracyclines (high resistance rates), sulfonamides, trimethoprim-sulfamethoxazole (do not eradicate GAS), or older fluoroquinolones like ciprofloxacin (limited GAS activity) 2
• Do NOT prescribe broad-spectrum antibiotics unnecessarily when narrow-spectrum options are effective 3

Special Circumstances: Recurrent Pharyngitis

Patients with recurrent positive GAS tests may actually be chronic pharyngeal carriers experiencing repeated viral infections rather than true recurrent GAS pharyngitis. 1, 2

Chronic Carrier Management

• Chronic GAS carriers do NOT ordinarily require antimicrobial therapy because they are unlikely to spread infection and are at little risk for complications 1, 2
• Do NOT routinely identify or treat chronic carriers 1, 2
• Treatment of carriers is justified ONLY in special circumstances: community outbreak of rheumatic fever, family history of rheumatic fever, or excessive family anxiety 2

When Symptoms Persist After Treatment

• Consider clindamycin, amoxicillin-clavulanate, or narrow-spectrum cephalosporin as these achieve higher eradication rates 2
• Intramuscular benzathine penicillin G if oral compliance is questionable 2

Red Flags Requiring Urgent Evaluation

Patients with unusually severe signs should be evaluated for rare but life-threatening throat infections: difficulty swallowing, drooling, neck tenderness or swelling suggest peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome 1

• Remain vigilant for Lemierre syndrome in adolescents and young adults with severe pharyngitis—urgent diagnosis and treatment is necessary to prevent complications and death 1

Tonsillectomy Considerations

Tonsillectomy solely to reduce the frequency of GAS pharyngitis in adults is NOT recommended. 1