What are the symptoms and treatment options for streptococcal (strep) pharyngitis?

From the Guidelines

Strep pharyngitis should be treated with a 10-day course of oral penicillin V or amoxicillin, with alternatives including azithromycin or clindamycin for penicillin-allergic patients, as recommended by the most recent and highest quality study 1. The treatment of strep pharyngitis typically involves antibiotics to prevent complications and reduce symptom duration.

• The first-line treatment is penicillin V (250-500 mg twice daily for adults, weight-based dosing for children) or amoxicillin (500 mg twice daily for adults, 50 mg/kg/day divided twice daily for children) for 10 days, as supported by studies 1.
• For patients allergic to penicillin, alternatives include azithromycin (500 mg on day 1, then 250 mg daily for 4 days) or clindamycin (300 mg three times daily for 10 days), as suggested by guidelines 1.
• Diagnosis is confirmed through rapid strep tests or throat cultures, as symptoms alone cannot reliably distinguish strep from viral pharyngitis, emphasizing the importance of laboratory confirmation 1.
• Supportive care includes rest, adequate hydration, saltwater gargles, and over-the-counter pain relievers like acetaminophen or ibuprofen.
• Patients should stay home from work or school until they've been on antibiotics for 24 hours to prevent spreading the infection, highlighting the need for responsible infection control measures. The most recent and highest quality study 1 provides the basis for these recommendations, prioritizing the use of penicillin and amoxicillin as first-line treatments due to their efficacy, safety, and narrow spectrum of activity.

From the FDA Drug Label

In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum): otherwise the sequelae of streptococcal disease may occur. Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy

Strep Pharyngitis Treatment:

• The treatment for strep pharyngitis should be sufficient to eliminate the organism, with a minimum duration of 10 days.
• Penicillin is the usual first-line therapy, but azithromycin can be used as an alternative in individuals who cannot use first-line therapy 2 3.
• It is essential to complete the full course of therapy to prevent the development of resistance and ensure the eradication of the organism.

From the Research

Symptoms of Strep Pharyngitis

• Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4 degrees F (38 degrees C), tonsillar exudates, and cervical adenopathy 4
• Cough, coryza, and diarrhea are more common with viral pharyngitis 4
• The strongest independent predictors of GABHS pharyngitis are patient age of five to 15 years, absence of cough, tender anterior cervical adenopathy, tonsillar exudates, and fever 5

Diagnosis of Strep Pharyngitis

• Available diagnostic tests include throat culture and rapid antigen detection testing 4
• Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly 4
• The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 4, 5

Treatment of Strep Pharyngitis

• Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness 4
• Amoxicillin is equally effective and more palatable 4, 6
• Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy 4, 6
• Azithromycin versus penicillin V for treatment of acute group A streptococcal pharyngitis showed similar high levels of clinical efficacy, but lower levels of bacteriologic eradication 7
• Different antibiotic treatments for group A streptococcal pharyngitis showed that cephalosporins versus penicillin may have a difference in symptom resolution, but the evidence is uncertain 8

Prevention and Complications

• Chronic GABHS colonization is common despite appropriate use of antibiotic therapy 4
• Chronic carriers are at low risk of transmitting disease or developing invasive GABHS infections, and there is generally no need to treat carriers 4
• Tonsillectomy is rarely recommended as a preventive measure, with specific thresholds for considering surgery 6