From the Guidelines
Prednisone is not recommended for routine symptom management in strep pharyngitis when antibiotics are being used. The standard treatment for strep throat is antibiotics alone, typically penicillin (such as amoxicillin 50 mg/kg once daily, max 1000 mg, for 10 days) or, for penicillin-allergic patients, azithromycin (12 mg/kg once daily, max 500 mg, for 5 days) or clindamycin (7 mg/kg/dose three times daily, max 300 mg/dose, for 10 days) 1. Adding corticosteroids like prednisone to this regimen provides minimal additional benefit for most patients and introduces unnecessary risks including immunosuppression, which could potentially interfere with fighting the infection. Symptom management is better achieved with over-the-counter pain relievers like acetaminophen or ibuprofen, warm salt water gargles, and adequate hydration.
Key Considerations
- The diagnosis of strep pharyngitis should be established through accurate testing, as the signs and symptoms of GAS and nonstreptococcal pharyngitis overlap broadly 1.
- Antibiotic therapy is effective in treating group A streptococcal pharyngitis, with penicillin remaining the treatment of choice due to its proven efficacy, safety, narrow spectrum, and low cost 1.
- The use of corticosteroids like prednisone is not supported by the evidence as a standard treatment for symptom management in strep pharyngitis, and their use may introduce unnecessary risks.
Symptom Management
- Over-the-counter pain relievers like acetaminophen or ibuprofen can help manage symptoms.
- Warm salt water gargles and adequate hydration are also recommended for symptom relief.
- In very severe cases with significant inflammation causing airway concerns or extreme difficulty swallowing, a short course of corticosteroids might be considered, but this would be an exception rather than standard practice.
From the Research
Symptom Management with Antibiotics for Strep Pharyngitis
- The use of prednisone for symptom management with antibiotics for strep pharyngitis is not recommended, as steroids are not recommended for symptomatic treatment 2.
- Nonsteroidal anti-inflammatory drugs are more effective than acetaminophen and placebo for treatment of fever and pain associated with GABHS pharyngitis; medicated throat lozenges used every two hours are also effective 3.
- Corticosteroids provide only a small reduction in the duration of symptoms and should not be used routinely 3.
Antibiotic Treatment for Strep Pharyngitis
- Penicillin and amoxicillin are first-line antibiotics, with a recommended course of 10 days; first-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 2.
- Erythromycin is a traditional alternative to penicillins, especially in penicillin-allergic patients, for the treatment of tonsillopharyngitis, but increased resistance and failure rates have been reported 4.
- Cephalosporins are useful especially for the treatment of recurrent streptococcal tonsillopharyngitis 4.
Diagnosis of Strep Pharyngitis
- Guidelines recommend using clinical decision rules to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear, before prescribing antibiotics 2.
- A rapid antigen detection test should be ordered in patients with a modified Centor or FeverPAIN score of 2 or 3 3.
- Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly 5.