What is the recommended treatment for a patient with pharyngitis?

Treatment of Pharyngitis

For confirmed Group A Streptococcal (GAS) pharyngitis, treat with penicillin or amoxicillin for 10 days; for viral pharyngitis, provide symptomatic management with acetaminophen or NSAIDs and avoid antibiotics entirely. 1, 2

Diagnostic Approach: Distinguish Bacterial from Viral

Before initiating treatment, proper diagnosis is essential to avoid unnecessary antibiotic use:

• Do not test or treat patients with clear viral features including cough, rhinorrhea, hoarseness, or oral ulcers 1, 2
• Test for GAS when viral features are absent using rapid antigen detection test (RADT) or throat culture 1
• In children and adolescents, back up negative RADTs with throat culture due to higher risk of acute rheumatic fever 1
• In adults, backup cultures after negative RADT are not routinely necessary given the low incidence of GAS and exceptionally low risk of acute rheumatic fever 1
• Do not test children under 3 years old unless special risk factors exist (such as an older sibling with GAS infection), as acute rheumatic fever is rare in this age group 1

Antibiotic Treatment for Confirmed GAS Pharyngitis

First-Line Therapy

• Penicillin or amoxicillin for 10 days is the treatment of choice based on narrow spectrum, low adverse effects, modest cost, and proven efficacy in preventing acute rheumatic fever 1, 2
• The 10-day duration is necessary to eradicate the organism from the pharynx and prevent complications 1

Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: first-generation cephalosporin for 10 days 1, 3
• For anaphylactic or beta-lactam allergy: clindamycin for 10 days or azithromycin for 5 days 1
• Exercise caution with azithromycin and clarithromycin due to significant resistance in some U.S. regions 3

Azithromycin Efficacy Data

• Azithromycin (12 mg/kg once daily for 5 days in children) demonstrated 95% bacteriologic eradication at Day 14 compared to 73% with penicillin V, and 98% clinical success compared to 84% with penicillin 4
• However, approximately 1% of azithromycin-susceptible S. pyogenes isolates became resistant following therapy 4

Symptomatic Management (All Pharyngitis)

Analgesic/Antipyretic Therapy

• Use acetaminophen or NSAIDs for moderate to severe symptoms or high fever as adjunct to antibiotics in GAS pharyngitis, or as primary treatment in viral pharyngitis 1, 2
• NSAIDs (such as ibuprofen) are more effective than acetaminophen for fever and pain control 5
• Never use aspirin in children due to risk of Reye syndrome 1, 2

Topical Agents

• Topical anesthetics (ambroxol, lidocaine, benzocaine) in rinses, sprays, or lozenges may provide temporary relief 1, 2
• Lozenges represent a choking hazard in young children and should be avoided 1
• Warm salt water gargles can provide symptom relief for patients old enough to gargle 1, 2

What NOT to Use

• Do not use corticosteroids routinely - they provide only minimal benefit (approximately 5 hours of pain reduction) with potential adverse effects including immunosuppression, glucose dysregulation, and mood changes 1, 5
• The self-limited nature of GAS pharyngitis and efficacy of antibiotics plus analgesics make corticosteroids unnecessary 1, 5

Viral Pharyngitis: Symptomatic Treatment Only

• Never prescribe antibiotics for viral pharyngitis - they provide no benefit and contribute to antibiotic resistance 2
• Provide acetaminophen or NSAIDs for symptom control 2
• Reassure patients that typical sore throat duration is less than one week 2

Special Considerations and Common Pitfalls

Recurrent Pharyngitis

• Patients with recurrent positive GAS tests may be chronic carriers experiencing repeated viral infections rather than true recurrent streptococcal infections 1
• Chronic GAS carriers do not require antimicrobial therapy as they are unlikely to spread infection or develop complications 1
• Do not perform tonsillectomy solely to reduce GAS pharyngitis frequency 1

Follow-Up

• Routine post-treatment cultures or RADTs are not recommended 1
• Reevaluate patients with worsening symptoms after appropriate antibiotic initiation or symptoms lasting 5 days after treatment start 3

Key Pitfalls to Avoid

• Do not prescribe antibiotics empirically without testing - 60% of adults with sore throat receive antibiotics despite only 10% having GAS pharyngitis 3
• Do not assume penicillin provides significant early symptomatic benefit - studies show only 20% improvement over anti-inflammatory therapy alone after 48 hours 6
• Do not confuse PFAPA syndrome with recurrent streptococcal pharyngitis in patients with periodic fever 7
• Do not test or treat asymptomatic household contacts 1