What is the best course of treatment for a patient with severe throat pain and a negative strep (streptococcal) antigen test?

Management of Severe Throat Pain with Negative Strep Test

For a patient with severe throat pain and a negative strep antigen test, withhold antibiotics and provide symptomatic treatment only with NSAIDs or acetaminophen, as the infection is almost certainly viral and antibiotics provide no benefit while carrying risk of adverse effects. 1

Diagnostic Interpretation

Adults

• A negative rapid antigen detection test (RADT) alone is sufficient to rule out group A streptococcal pharyngitis in adults—no backup throat culture is needed 1, 2
• The specificity of RADT is ≥95%, making false positives rare, while sensitivity is 80-90% 1
• Adults have only 5-10% prevalence of group A streptococcal pharyngitis and extremely low risk of acute rheumatic fever, making the risk-benefit ratio strongly favor withholding antibiotics 1

Children and Adolescents

• In children and adolescents, a negative RADT requires confirmation with a throat culture before making final treatment decisions, as rapid tests miss 10-20% of true infections 1, 2
• Treatment can be safely initiated within 9 days of symptom onset if the culture returns positive, which still effectively prevents acute rheumatic fever 1, 2
• While awaiting culture results, provide analgesics/antipyretics for symptom relief 1

Treatment Approach

Symptomatic Management

• Either ibuprofen or acetaminophen are recommended for relief of acute sore throat symptoms 1
• NSAIDs are more effective than acetaminophen for treatment of fever and pain associated with pharyngitis 3
• Throat lozenges used every two hours are also effective 3
• Provide reassurance that symptoms typically resolve in less than 1 week without antibiotics 1

Why Antibiotics Should Be Withheld

• Up to 70% of patients with sore throats receive unnecessary antibiotic prescriptions, while only 20-30% actually have group A streptococcal pharyngitis 1
• Antibiotics shorten sore throat duration by only 1-2 days, with a number needed to treat of 6 at 3 days and 21 at 1 week 1
• The primary justification for treating confirmed streptococcal pharyngitis is prevention of acute rheumatic fever, peritonsillar abscess, and spread during outbreaks—not symptom relief 1
• Viruses cause the majority of acute pharyngitis cases, including adenovirus, influenza, parainfluenza, rhinovirus, respiratory syncytial virus, coxsackievirus, echoviruses, and herpes simplex virus 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on severity of symptoms alone—the presence of severe pain, white patches, or exudate can occur with viral infections and does not reliably distinguish bacterial from viral causes 1
• Do not treat household contacts prophylactically—testing or empiric treatment of asymptomatic contacts is not recommended 1
• Do not switch from one antibiotic to another without microbiological indication, as this increases the risk of adverse effects without clinical benefit 1

When to Reconsider

• If symptoms persist beyond 3-4 days or worsen significantly, consider suppurative complications (such as peritonsillar abscess) or alternative diagnoses 1
• In patients with high risk of rheumatic fever or with severe symptoms, clinical judgment should be used, but generally antibiotics should still be withheld with negative tests 1

Special Considerations for Viral Etiology

• The presence of cough, rhinorrhea, conjunctivitis, coryza, hoarseness, discrete ulcerative stomatitis, or viral exanthem strongly suggests viral etiology 1, 4
• A negative mono test excludes Epstein-Barr virus infectious mononucleosis, which commonly presents with severe pharyngitis, tonsillar exudate, and white patches 1