Management of Viral Pharyngitis and Strep Throat in Pediatric Patients
Most pediatric pharyngitis is viral and requires only symptomatic treatment, while confirmed Group A streptococcal (GAS) pharyngitis should be treated with penicillin or amoxicillin for 10 days to prevent acute rheumatic fever. 1
Diagnostic Approach
When to Test for Strep
Do NOT test in the following situations:
- Children under 3 years of age (except when an older sibling has confirmed GAS infection) 1, 2, 3
- Any child with clear viral features: cough, rhinorrhea, hoarseness, conjunctivitis, or oral ulcers 1
DO test when:
- Age 5-15 years with acute pharyngitis without viral features 1
- Sudden onset sore throat, fever, tonsillopharyngeal erythema, tender anterior cervical lymphadenopathy, or scarlatiniform rash 1
Testing Method
For children and adolescents:
- Perform rapid antigen detection test (RADT) first 1
- Always back up negative RADT with throat culture (sensitivity of RADT is only 80-90%) 1, 4
- Positive RADT does not require culture confirmation (specificity >95%) 1, 4
For adults:
- RADT alone is sufficient; backup culture not needed for negative results 1
Common pitfall: Testing children under 3 years leads to identification of asymptomatic carriers rather than true infections, resulting in unnecessary antibiotic use 2, 3
Treatment of Confirmed GAS Pharyngitis
First-Line Antibiotic Therapy
Penicillin or amoxicillin for 10 days is the recommended treatment based on narrow spectrum, low adverse effects, and modest cost 1
For penicillin-allergic patients:
- First-generation cephalosporin (if no severe allergy) 1
- Clindamycin 1
- Clarithromycin 1
- Azithromycin: 12 mg/kg once daily for 5 days (maximum 500 mg/day) 5
Treatment initiated within 9 days of symptom onset still prevents acute rheumatic fever 4
Adjunctive Symptomatic Treatment
- Acetaminophen or ibuprofen for moderate to severe symptoms or high fever 1, 3
- Never use aspirin in children (risk of Reye syndrome) 1, 3
- Corticosteroids are not recommended 1
Management of Viral Pharyngitis
Symptomatic treatment only:
- Analgesics/antipyretics (acetaminophen or ibuprofen) 4, 3
- Throat lozenges 4
- Reassurance that symptoms typically resolve in less than 1 week 4
Common viral causes include: adenovirus, parainfluenza, rhinovirus, respiratory syncytial virus, coxsackievirus, herpes simplex virus, and Epstein-Barr virus 1, 6
What NOT to Do
Do not test or treat:
- Asymptomatic household contacts of patients with GAS pharyngitis 1, 4
- Patients after completing appropriate antibiotic treatment (post-treatment cultures not routinely indicated) 1, 4
Do not prescribe antibiotics:
- For negative strep tests (even with exudates or white patches, which can be viral) 4
- Based on clinical appearance alone without laboratory confirmation 4
- For children under 3 years without specific risk factors 2, 3
Special Considerations by Age
Children Under 3 Years
- GAS pharyngitis is uncommon and presents atypically (mucopurulent rhinitis, excoriated nares, diffuse adenopathy rather than exudative pharyngitis) 3
- Acute rheumatic fever is extremely rare (only 5% of cases occur in children under 5 years) 3
- Focus on symptomatic treatment unless older sibling has confirmed GAS infection 2, 3
Children 5-15 Years
- Peak age for GAS pharyngitis (20-30% of acute pharyngitis cases) 2, 4
- Always back up negative RADT with throat culture 1, 4
- Treatment prevents acute rheumatic fever, suppurative complications, and transmission 7, 8
Key Clinical Pitfalls to Avoid
Overtesting young children: Leads to treating asymptomatic carriers and unnecessary antibiotic resistance 2, 3
Not obtaining backup culture in children with negative RADT: Misses 10-20% of true GAS infections 4
Treating based on appearance alone: White patches and exudates occur with both viral and bacterial infections 4
Testing or treating household contacts: Up to one-third of households include asymptomatic GAS carriers; prophylaxis does not reduce subsequent infection rates 4
Post-treatment testing: Does not distinguish between asymptomatic carriers and active infection 4