What is the management of pharyngitis?

Management of Pharyngitis

Diagnostic Approach: Laboratory Confirmation is Essential

Clinical diagnosis alone is unreliable—laboratory confirmation with rapid antigen detection test (RADT) or throat culture is required because signs and symptoms of Group A Streptococcal (GAS) and viral pharyngitis overlap too broadly for accurate clinical differentiation. 1

Testing Algorithm by Age Group

• Adults: Perform RADT in patients with clinical features suggesting bacterial infection; a negative RADT is sufficient to rule out streptococcal pharyngitis without confirmatory culture 2
• Children: Confirm all negative RADTs with throat culture due to higher GAS prevalence and rheumatic fever risk 2
• Children under 3 years: Do not routinely test, as GAS pharyngitis and rheumatic fever are rare in this age group 2

Clinical Features Suggesting GAS Testing

• Sudden onset of sore throat with fever 3
• Tender anterior cervical lymphadenopathy 4
• Tonsillar exudates 4
• Absence of cough and nasal symptoms 4, 3
• Patient age 5-15 years 4

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Treatment of Confirmed GAS Pharyngitis

For patients without penicillin allergy, oral penicillin V or amoxicillin for 10 days is the standard of care and remains the drug of choice due to proven efficacy, narrow spectrum, safety, and low cost—with no documented penicillin resistance in GAS anywhere in the world. 2, 5

First-Line Treatment (No Penicillin Allergy)

• Amoxicillin: 50 mg/kg/day once daily (maximum 1000 mg) for 10 days—offers improved adherence with once-daily dosing 2
• Penicillin V: Standard dosing for 10 days 2, 6
• Intramuscular benzathine penicillin G: Single dose (600,000 U for <27 kg; 1,200,000 U for ≥27 kg) for patients unlikely to complete oral therapy 2

Penicillin-Allergic Patients: Treatment Algorithm

For non-anaphylactic penicillin allergy (delayed rash, non-severe reactions):

• First-generation cephalosporins (cephalexin 500 mg twice daily or cefadroxil 1000 mg once daily) for 10 days—cross-reactivity risk is only 0.1% in non-severe reactions 2, 5

For immediate/anaphylactic penicillin allergy (anaphylaxis, angioedema, urticaria within 1 hour):

• Clindamycin 300 mg three times daily (7 mg/kg/dose in children, max 300 mg) for 10 days—preferred choice with only 1% resistance rate in the United States 2, 5
• Azithromycin 500 mg day 1, then 250 mg days 2-5 (12 mg/kg once daily in children, max 500 mg)—only requires 5 days but has 5-8% resistance rate 2, 5
• Clarithromycin 250 mg twice daily for 10 days 2

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—shortening the course by even a few days dramatically increases treatment failure rates. 2, 5

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Treatment of Viral (Strep-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing—antimicrobial therapy is of no proven benefit for viral pharyngitis. 1, 2

Symptomatic Management

• NSAIDs (ibuprofen): Provide superior pain relief compared to acetaminophen for moderate to severe symptoms or high fever 2, 4
• Acetaminophen: Alternative for pain and fever control 2
• Warm salt water gargles: Can provide symptomatic relief 2
• Medicated throat lozenges: Used every 2 hours are effective 4
• Avoid aspirin in children: Risk of Reye syndrome 2

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

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Common Pitfalls to Avoid

• Never treat based on clinical symptoms alone without laboratory confirmation—this leads to massive antibiotic overuse 2
• Do not use these antibiotics for GAS pharyngitis: Tetracyclines (high resistance), sulfonamides, trimethoprim-sulfamethoxazole (do not eradicate GAS), or ciprofloxacin (limited GAS activity) 2, 7
• 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
• Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions—up to 10% cross-reactivity risk 1, 5
• Do not prescribe shorter courses than recommended (except azithromycin's 5-day regimen)—this increases treatment failure and rheumatic fever risk 2, 5

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Special Circumstances: Recurrent or Persistent Pharyngitis

If Symptoms Persist After Completing Therapy

Consider that the patient may be a chronic GAS carrier experiencing intercurrent viral infections rather than true recurrent GAS pharyngitis—obtain repeat throat culture or RADT to determine if GAS is still present. 1, 2

Treatment Failure (Positive Culture After Completing Penicillin)

• Clindamycin 300 mg three times daily for 10 days—preferred for treatment failure with approximately 1% resistance 2, 7
• Amoxicillin-clavulanate 875 mg twice daily for 10 days—addresses beta-lactamase-producing co-pathogens 2, 7
• Intramuscular benzathine penicillin G if oral compliance is questionable 1, 2

Chronic GAS Carriers

Do not routinely identify or treat chronic GAS carriers—they are at little risk for complications or spreading infection and do not ordinarily require antimicrobial therapy. 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

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Key Clinical Points

• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 2
• Primary goal of treatment is preventing acute rheumatic fever, not just symptom relief—this requires adequate bacterial eradication 1, 2
• Group C and Group G streptococcal pharyngitis do not cause rheumatic fever and do not require the same treatment approach 2
• Therapy can be safely postponed up to 9 days after symptom onset and still prevent acute rheumatic fever 5