What is the treatment for an adult or child with no significant medical history and pharyngitis?

Treatment of Pharyngitis

Antibiotics should only be prescribed for pharyngitis when Group A Streptococcus (GAS) is confirmed by rapid antigen detection test (RADT) or throat culture, as only bacterial pharyngitis benefits from antibiotic therapy, while the majority of cases are viral and self-limited. 1

Diagnostic Approach

Testing Strategy

• Perform RADT in patients with clinical features suggesting bacterial infection (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) 1
• Do not test patients with clear viral features (cough, rhinorrhea, hoarseness, oral ulcers) as these strongly suggest viral etiology 2, 3
• In children under 3 years, RADT is usually not performed as GAS is rarely involved in this age group 1
• Throat cultures are not recommended for routine evaluation when RADT sensitivity exceeds 80%, but may be considered in high-risk situations (history of rheumatic fever, ages 5-25 in crowded conditions, endemic regions) 1, 4

Clinical Decision Rules

For adults, use the Centor criteria (fever, tonsillar exudates, no cough, tender anterior cervical lymphadenopathy):

• 0-1 criteria: No testing or treatment needed 4, 3
• 2-3 criteria: Perform RADT and treat only if positive 4, 3
• 4 criteria: Either perform RADT or treat empirically 4, 3

Antibiotic Treatment for Confirmed GAS Pharyngitis

First-Line Therapy

Penicillin V or amoxicillin for 10 days is the recommended first-line treatment for confirmed GAS pharyngitis 1, 2, 5, 6, 4

• Penicillin V remains the gold standard with Grade A evidence for preventing acute rheumatic fever 1
• These agents provide rapid symptom resolution, eradication of GAS, and prevention of complications 1

Penicillin-Allergic Patients

For patients with penicillin allergy:

• First-generation cephalosporins (if no history of severe/anaphylactic reaction) 1, 6
• Clindamycin (resistance rate approximately 1% in the United States) 1, 6
• Macrolides (erythromycin, clarithromycin, or azithromycin) with important caveats 1, 6:
  • Macrolide resistance rates are 5-8% in most U.S. areas 1
  • 10 days of clarithromycin may be more effective than 5 days of azithromycin 1
  • Azithromycin dosing: 12 mg/kg/day (maximum 500 mg) for 5 days 1, 7
  • Erythromycin has substantially higher gastrointestinal side effects 1

Symptomatic Management

Pain and Fever Control

NSAIDs (such as ibuprofen) or acetaminophen should be offered as adjunctive therapy for moderate to severe symptoms or fever control 1, 2, 6

• NSAIDs are more effective than acetaminophen for pain and fever reduction 1, 6
• Aspirin must be avoided in children due to risk of Reye syndrome 1, 2

Additional Symptomatic Measures

• Topical anesthetics (lozenges containing ambroxol, lidocaine, or benzocaine) may provide temporary relief 1, 2
• Warm salt water gargles can be used in patients old enough to gargle 1, 2

What NOT to Use

Corticosteroids are not recommended for routine treatment of pharyngitis 1, 8, 9

• While they reduce pain duration by approximately 5 hours, this minimal benefit does not justify potential adverse effects 1, 8, 9
• The self-limited nature of GAS pharyngitis and effectiveness of antibiotics plus analgesics make steroids unnecessary 8, 9

Common Pitfalls to Avoid

Antibiotic Overuse

• Do not prescribe antibiotics for viral pharyngitis (negative RADT with low-risk features) as this provides no benefit and contributes to antibiotic resistance 1, 2, 10
• Studies show 21% of patients with negative rapid strep tests still receive antibiotics inappropriately 10

Testing Errors

• Do not rely on clinical features alone to diagnose GAS pharyngitis, as no clinical signs or scores have adequate predictive value 1
• The majority of adult pharyngitis (85-90%) is viral and self-limited 4, 3

Treatment Duration

• Ensure 10-day treatment courses for penicillin and amoxicillin (except azithromycin which is 5 days) to prevent treatment failure and complications 1, 5
• Good compliance must be emphasized to patients 1