What is the appropriate treatment approach for a patient with pharyngitis?

Treatment of Pharyngitis

Antibiotics should only be prescribed for pharyngitis when group A streptococcal (GAS) infection is confirmed by rapid antigen detection test (RADT) or throat culture—most pharyngitis is viral and does not require antibiotics. 1

Diagnostic Approach

When to Test for GAS

• Test patients only when clinical features suggest bacterial infection: persistent fever, tender anterior cervical lymph nodes, tonsillopharyngeal exudates, and absence of cough, rhinorrhea, or other viral symptoms 1, 2
• Do not test patients with fewer than 3 Centor criteria (fever, tonsillar exudates, tender anterior cervical adenopathy, absence of cough), as they have low probability of GAS pharyngitis 1
• Viral features such as cough, rhinorrhea, hoarseness, conjunctivitis, and oral ulcers strongly suggest viral etiology and testing is not warranted 2, 3

Testing Methods

• RADT is the preferred initial test with sensitivity of 80-90% and specificity ≥95% 2, 4
• In adults, a negative RADT is sufficient to rule out GAS pharyngitis—backup throat culture is not necessary due to low incidence of GAS and extremely low risk of acute rheumatic fever 1, 2
• In children and adolescents, confirm negative RADT with throat culture due to higher prevalence of GAS (20-30%) and greater risk of acute rheumatic fever 2, 4
• Children under 3 years should generally not be tested, as acute rheumatic fever is rare in this age group 4

Antibiotic Treatment for Confirmed GAS Pharyngitis

First-Line Therapy

• Penicillin V or amoxicillin for 10 days is the treatment of choice for confirmed GAS pharyngitis based on narrow spectrum, low cost, proven efficacy, and prevention of acute rheumatic fever 1, 4, 5, 6
• The 10-day duration is necessary to eradicate GAS from the pharynx and prevent complications 4, 5
• Treatment initiated within 9 days of symptom onset still effectively prevents acute rheumatic fever 2

Penicillin-Allergic Patients

• First-generation cephalosporins are the preferred alternative for penicillin-allergic patients 7, 4, 8
• Clindamycin or macrolides (clarithromycin, azithromycin) are acceptable alternatives, though local resistance patterns should be considered 7, 4, 8
• Azithromycin can be given for 5 days as an alternative regimen 7, 9

Clinical Benefits of Antibiotics

• Antibiotics shorten sore throat duration by only 1-2 days, with number needed to treat of 6 at 3 days and 21 at 1 week 1
• The primary justification for treating GAS pharyngitis is prevention of acute rheumatic fever, peritonsillar abscess, and limiting spread during outbreaks—not symptom relief 1, 2
• Antibiotics do not prevent post-streptococcal glomerulonephritis 1, 2

Symptomatic Management

Analgesics and Antipyretics

• All patients with pharyngitis should be offered symptomatic treatment with acetaminophen or NSAIDs (ibuprofen) for pain and fever relief 1, 2, 7, 4
• NSAIDs are more effective than acetaminophen for fever and pain control 4
• Throat lozenges can provide additional symptomatic relief 1, 2
• Avoid aspirin in children due to risk of Reye syndrome 4

Topical Therapies

• Salt water gargles, viscous lidocaine, and other topical mixtures are commonly used but have limited evidence supporting their efficacy 1, 7

Patient Education

• Reassure patients that typical sore throat resolves in less than 1 week and antibiotics provide minimal symptomatic benefit while carrying risk of adverse effects 1, 2
• Most pharyngitis (>60% of cases) is viral and self-limited 1

Important Pitfalls to Avoid

Overuse of Antibiotics

• More than 60% of adults with sore throat receive unnecessary antibiotic prescriptions, despite most cases being viral 1
• Treating based on clinical appearance alone (such as exudates or white patches) without laboratory confirmation leads to antibiotic overuse, as these findings overlap between viral and bacterial causes 2

Testing and Treatment Errors

• Do not test or treat asymptomatic household contacts—they are likely carriers and do not require treatment 1, 2, 4
• Do not perform routine post-treatment cultures or RADTs in asymptomatic patients after completing appropriate antibiotic therapy 2, 4
• Chronic GAS carriers (positive culture without acute infection) should not receive antibiotics, as they are unlikely to spread infection and are at minimal risk for complications 1

Special Circumstances Requiring Urgent Evaluation

• Patients with severe symptoms such as difficulty swallowing, drooling, neck tenderness, or swelling require urgent evaluation for rare but life-threatening conditions including peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome 1
• Remain vigilant for Lemierre syndrome in adolescents and young adults with severe pharyngitis, as urgent diagnosis and treatment is necessary to prevent complications and death 1

Tonsillectomy

• Tonsillectomy solely to reduce frequency of GAS pharyngitis in adults is not recommended 1, 4