What is the appropriate treatment for a 25-year-old female with a 4-day history of significant sore throat and aphonia, presenting with erythematous (red) tonsils and palate petechiae?

Treatment of Group A Streptococcal Pharyngitis

This patient requires immediate confirmation of Group A Streptococcal (GAS) pharyngitis with rapid antigen detection testing (RADT), followed by antibiotic therapy if positive—penicillin V 500 mg twice daily or amoxicillin 1000 mg once daily for 10 days is first-line treatment. 1, 2

Diagnostic Confirmation Required

The clinical presentation—significant sore throat, aphonia, erythematous tonsils, and palate petechiae in a 25-year-old—is highly suggestive of GAS pharyngitis, but laboratory confirmation is mandatory before initiating antibiotics because clinical features alone cannot reliably distinguish bacterial from viral pharyngitis. 1, 3

• Perform RADT immediately—a positive result confirms GAS and justifies antibiotic therapy without need for backup culture. 1, 2
• If RADT is negative, obtain a throat culture for confirmation, as RADT sensitivity is approximately 90% and false negatives occur. 1
• Do not rely on clinical scoring alone to make treatment decisions—even with multiple Centor criteria present, testing is required. 1, 4

First-Line Antibiotic Treatment

Once GAS is confirmed, initiate antibiotics promptly:

Preferred Regimens (Non-Allergic Patients)

• Penicillin V 500 mg orally twice daily for 10 days (or 250 mg four times daily for 10 days). 1, 2
• Amoxicillin 1000 mg orally once daily for 10 days may enhance adherence compared to multiple daily dosing. 2
• Intramuscular benzathine penicillin G 1.2 million units as a single dose if adherence to oral therapy is questionable. 1, 2

Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: First-generation cephalosporins (cephalexin or cefadroxil) for 10 days. 1, 5, 2
• For anaphylactic penicillin allergy: Clindamycin, azithromycin, or clarithromycin. 5, 2
  • Note: Azithromycin is the only antibiotic approved for a 5-day course, but significant resistance exists in some U.S. regions. 2, 6

Critical Treatment Duration

The 10-day course is non-negotiable for penicillin, amoxicillin, and first-generation cephalosporins—this duration maximizes bacterial eradication and prevents acute rheumatic fever (ARF), which can develop 2-4 weeks after the initial infection. 1, 7, 2

• Shorter courses (5 days) of standard-dose penicillin are less effective for GAS eradication and should be avoided. 5, 2
• Treatment can be safely initiated up to 9 days after symptom onset and still prevent ARF. 1

Symptomatic Management

All patients require symptomatic relief regardless of antibiotic use:

• NSAIDs (ibuprofen) are more effective than acetaminophen for pain and fever control. 5, 2, 3
• Avoid aspirin in younger patients due to Reye syndrome risk. 2
• Medicated throat lozenges used every 2 hours provide additional relief. 3
• Corticosteroids are not recommended—they provide only minimal symptom reduction and should not be used routinely. 3

Common Pitfalls to Avoid

• Do not treat without microbiological confirmation—60% of adults with sore throat receive antibiotics, but only 10% have GAS pharyngitis. 6
• Do not prescribe broad-spectrum antibiotics when narrow-spectrum penicillin is effective and prevents resistance. 1, 2
• Do not use courses shorter than 10 days for penicillin or amoxicillin—this increases treatment failure risk. 5, 2
• Do not order follow-up throat cultures for asymptomatic patients who completed appropriate therapy, as most will be chronic carriers rather than having persistent infection. 1, 2

When to Reevaluate

• If symptoms worsen after 48-72 hours of appropriate antibiotic therapy or persist beyond 5 days after treatment initiation, reevaluate for complications or alternative diagnoses. 6
• Consider peritonsillar abscess, deep space infections, or the possibility of chronic GAS carriage with intercurrent viral infection. 5, 8
• If fever of 103°F occurs 3 weeks after treatment, immediately evaluate for ARF or post-streptococcal glomerulonephritis (PSGN)—this timing is classic for these nonsuppurative complications. 7

Special Considerations for This Patient

The 4-day symptom duration and presence of aphonia (voice loss) suggest significant pharyngeal inflammation. While awaiting test results:

• Initiate symptomatic treatment with NSAIDs immediately. 5, 2
• If clinical suspicion is extremely high and patient cannot return for results, consider starting antibiotics while awaiting confirmation, but discontinue if testing is negative. 1
• The presence of palate petechiae increases likelihood of GAS but can also occur with infectious mononucleosis—ensure testing specifically identifies GAS. 1, 3