What is the treatment for pharyngitis?

Treatment of Pharyngitis

For confirmed Group A Streptococcal (GAS) pharyngitis, treat with penicillin or amoxicillin for 10 days; for viral pharyngitis (suggested by cough, rhinorrhea, hoarseness, or oral ulcers), provide symptomatic care only without antibiotics. 1

Distinguishing Bacterial from Viral Pharyngitis

The critical first step is determining whether pharyngitis is bacterial or viral, as this fundamentally changes management:

Clinical Features Suggesting Viral Etiology (No Testing or Antibiotics Needed)

• Presence of cough, rhinorrhea (runny nose), hoarseness, or oral ulcers strongly suggests viral infection 1, 2
• Testing for GAS is not recommended when these viral features are present 1
• Antibiotics provide no benefit and contribute to resistance 2

When to Consider GAS Testing

• Test patients with 2 or more of the following Centor criteria: fever history, tonsillar exudates, absence of cough, and tender anterior cervical lymphadenopathy 3
• Use rapid antigen detection test (RADT) as first-line diagnostic; positive RADT is diagnostic and requires no backup culture 1
• Throat cultures are reserved for negative RADT results in children, but not routinely needed in adults with high-sensitivity RADTs 1, 3

Special Population Considerations

• Children under 3 years old do not require testing unless special risk factors exist (e.g., older sibling with GAS) because acute rheumatic fever is rare and classic presentation is uncommon in this age group 1

Antibiotic Treatment for Confirmed GAS Pharyngitis

First-Line Therapy (Non-Penicillin Allergic)

• Penicillin or amoxicillin for 10 days is the drug of choice based on narrow spectrum, safety, efficacy, and low cost 1
• The full 10-day course is mandatory to achieve maximal pharyngeal eradication and prevent acute rheumatic fever, even if symptoms resolve earlier 1, 4
• Intramuscular benzathine penicillin G is preferred for patients unlikely to complete oral therapy 1

Penicillin-Allergic Patients

• First-generation cephalosporins (e.g., cephalexin, cefadroxil) for 10 days in patients without anaphylactic penicillin sensitivity 1, 5
• For anaphylactic penicillin allergy: clindamycin for 10 days or clarithromycin for 10 days 1, 5
• Azithromycin for 5 days is an alternative, though macrolide resistance varies geographically and should be considered 1, 5, 6

Important Caveat on Augmentin (Amoxicillin-Clavulanate)

• Augmentin provides no additional benefit for routine GAS pharyngitis because Group A Streptococcus does not produce beta-lactamase 4
• Reserve for treatment failures or specific indications, not first-line therapy 4

Symptomatic Management (All Pharyngitis Types)

Pain and Fever Control

• Acetaminophen or NSAIDs for moderate to severe symptoms or high fever (NSAIDs are more effective than acetaminophen) 1, 2, 7
• Avoid aspirin in children due to Reye syndrome risk 1, 2, 5
• Medicated throat lozenges containing anesthetics (ambroxol, lidocaine, benzocaine) may provide temporary relief 2
• Warm salt water gargles can provide symptom relief for patients old enough to gargle 2

Corticosteroids: Not Recommended

• Corticosteroids provide only minimal symptom reduction (approximately 5 hours) with potential adverse effects 1, 2
• Should not be used routinely 1, 2, 7

Management of Recurrent Pharyngitis

Diagnostic Approach

• Confirm each episode with RADT or throat culture before treating 5
• Consider whether patient is experiencing true recurrent GAS infections versus being a chronic GAS carrier with repeated viral infections 1, 5

Chronic Carriers

• GAS carriers do not require identification efforts or antimicrobial therapy because they are unlikely to spread infection and are at little risk for complications 1
• Carriers should not be treated routinely 1

Tonsillectomy Considerations

• Tonsillectomy is not recommended solely to reduce frequency of GAS pharyngitis 1, 5
• May be considered only for children meeting specific frequency criteria: ≥7 episodes in 1 year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years, with documented confirmation of each episode 5

Post-Treatment Management

• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 4
• Routine follow-up throat cultures or RADT are not recommended for asymptomatic patients who completed therapy 1, 4
• Testing or treating asymptomatic household contacts is not routinely recommended 1

Common Pitfalls to Avoid

• Overdiagnosing and overtreating viral pharyngitis with antibiotics when clinical features suggest viral etiology 2
• Prescribing antibiotics without confirmatory testing in patients with intermediate clinical probability 3
• Using broad-spectrum antibiotics (like Augmentin) when narrow-spectrum agents are appropriate 4
• Failing to complete the full 10-day antibiotic course, which risks treatment failure and rheumatic fever 1, 4
• Using macrolides in geographic areas with high resistance rates 5
• Pursuing tonsillectomy without meeting established frequency criteria 1, 5