What is the treatment for pharyngitis (inflammation of the pharynx)?

Treatment of Pharyngitis

For confirmed Group A Streptococcal (GAS) pharyngitis, penicillin V or amoxicillin for 10 days is the first-line treatment; for viral pharyngitis, withhold antibiotics entirely and provide symptomatic care only. 1, 2

Diagnostic Approach: Test Before Treating

The critical first step is determining whether pharyngitis is bacterial or viral, as antibiotics benefit only GAS infections 1:

• Use modified Centor criteria to assess likelihood of GAS: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 2, 3
• Patients with 0-1 criteria: Do not test or treat—viral etiology is most likely 1, 2
• Patients with 2 criteria: Perform rapid antigen detection test (RADT); treat only if positive 1, 2
• Patients with 3-4 criteria: Perform RADT and treat if positive 1, 2, 4
• Children under 3 years: Do not routinely test, as GAS pharyngitis and rheumatic fever are rare in this age group 1, 5
• Negative RADT in children: Confirm with throat culture due to higher rheumatic fever risk 1, 5
• Negative RADT in adults: No confirmatory culture needed if test sensitivity exceeds 80% 1, 4

First-Line Antibiotic Treatment for Confirmed GAS

Penicillin or amoxicillin 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:

• Penicillin V: 250 mg orally 2-3 times daily for 10 days in adults; 40 mg/kg/day divided 2-3 times daily (maximum 750 mg/day) in children 1, 2
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days—preferred in children due to better taste and once-daily dosing 1, 2
• Intramuscular benzathine penicillin G: Single dose of 1.2 million units (≥27 kg) or 600,000 units (<27 kg) for patients unlikely to complete oral therapy 1, 5

The full 10-day course is essential to achieve maximal pharyngeal eradication and prevent acute rheumatic fever—shortening the course increases treatment failure rates 1, 2.

Treatment for Penicillin-Allergic Patients

The choice of alternative depends on the type of allergic reaction 1, 2, 6:

Non-Anaphylactic Penicillin Allergy

• First-generation cephalosporins (cephalexin 500 mg twice daily or cefadroxil 1 gram once daily for 10 days in adults; weight-based dosing in children) are preferred alternatives with only 0.1% cross-reactivity risk 1, 2, 6

Immediate/Anaphylactic Penicillin Allergy

Avoid all beta-lactams due to up to 10% cross-reactivity risk 1, 6:

• Clindamycin: 300 mg three times daily for 10 days in adults; 7 mg/kg three times daily (maximum 300 mg/dose) for 10 days in children—preferred choice with only ~1% resistance in the United States 1, 2, 6
• Azithromycin: 500 mg on day 1, then 250 mg days 2-5 in adults; 12 mg/kg once daily (maximum 500 mg) for 5 days in children—acceptable but 5-8% macrolide resistance exists 1, 2, 7
• Clarithromycin: 250 mg twice daily for 10 days in adults; 7.5 mg/kg twice daily (maximum 250 mg/dose) for 10 days in children 1, 2

Azithromycin is the only antibiotic requiring just 5 days due to its prolonged tissue half-life, but macrolide resistance varies geographically and should be considered 1, 2, 6.

Symptomatic Treatment for Viral (GAS-Negative) Pharyngitis

Withhold antibiotics entirely for patients with negative GAS testing, as most pharyngitis is viral and self-limited 1, 2, 5:

• NSAIDs (ibuprofen) or acetaminophen for moderate to severe symptoms or high fever—NSAIDs provide superior pain relief compared to acetaminophen 1, 2, 5
• Avoid aspirin in children due to Reye syndrome risk 1, 2
• Warm salt water gargles can provide symptomatic relief 5
• Do not use corticosteroids as adjunctive therapy—they provide only minimal benefit (approximately 5 hours pain reduction) with potential adverse effects 1, 2, 5

Critical 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, 5
• Do not use trimethoprim-sulfamethoxazole (Bactrim) for strep throat—it does not eradicate GAS and has 50% resistance rates 2, 5
• Do not use tetracyclines, sulfonamides, or ciprofloxacin for GAS pharyngitis due to high resistance or limited activity 5
• Do not perform routine follow-up throat cultures after completing therapy in asymptomatic patients 1, 2, 5
• Do not test or treat asymptomatic household contacts of patients with GAS pharyngitis 1, 5
• Do not shorten antibiotic courses below 10 days (except azithromycin's 5-day regimen)—this dramatically increases treatment failure and rheumatic fever risk 1, 2, 6

Special Considerations

• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 1, 5
• Recurrent pharyngitis: Consider that the patient may be a chronic GAS carrier experiencing repeated viral infections rather than true recurrent GAS pharyngitis 1, 2, 5
• Chronic GAS carriers: Do not routinely identify or treat, as they are at little risk for complications or spreading infection—treatment justified only in special circumstances (community outbreak of rheumatic fever, family history of rheumatic fever) 1, 5
• Treatment can be safely delayed up to 9 days after symptom onset and still prevent acute rheumatic fever, so waiting 24-48 hours for culture results does not increase rheumatic fever risk 1
• The primary goal of antibiotic treatment is preventing acute rheumatic fever, not just symptom relief—antibiotics shorten symptom duration by only 1-2 days but prevent serious complications 1, 2, 5