Best Antibiotics for Ongoing Sore Throat
Penicillin V (phenoxymethylpenicillin), given twice or three times daily for 10 days, remains the first-choice antibiotic for bacterial pharyngitis, with amoxicillin as an acceptable alternative in younger children due to taste and formulation considerations. 1, 2
When Antibiotics Are Actually Indicated
Before prescribing any antibiotic, you must first determine if antibiotics are warranted at all:
Do NOT prescribe antibiotics for patients with 0-2 Centor criteria (low probability of Group A Streptococcus), as these cases are predominantly viral and antibiotics provide no meaningful benefit 1, 2
For patients with 3-4 Centor criteria, consider rapid antigen testing before prescribing, and discuss with patients that antibiotic benefits are modest—shortening symptoms by only 1-2 days 1, 2
Most sore throats (>65%) are viral and resolve within one week without antibiotics 2, 3
First-Line Antibiotic Choice
Penicillin V is the gold standard for the following reasons:
- Group A β-hemolytic streptococci have shown zero resistance to penicillin over five decades of use 1
- Proven efficacy in preventing serious complications (rheumatic fever, peritonsillar abscess) 1
- Narrow spectrum minimizes disruption to normal flora and reduces selection pressure for resistance 1, 4
- Lowest cost option 1
Dosing: Penicillin V 250-500 mg twice or three times daily for 10 days 1, 2, 5
Alternative First-Line Options
Amoxicillin is an acceptable alternative, particularly in younger children:
- Equivalent efficacy to penicillin V (clinical cure rates 86% vs 92% respectively) 1
- Better palatability and available as suspension 1, 5
- Critical caveat: Avoid amoxicillin in older children and adolescents due to risk of severe rash if Epstein-Barr virus infection is present 1
Second-Line Antibiotics
For penicillin allergy:
- Cephalexin (first-generation cephalosporin) is preferred in regions with high macrolide resistance 1
- Clarithromycin for patients with severe penicillin allergy, though this is a Watch-category antibiotic requiring judicious use 1
Important note on cephalosporins: While meta-analyses show cephalosporins have statistically superior bacteriological cure rates (OR 2.29-2.34), the clinical differences are not clinically meaningful and do not justify their routine use over penicillin 1
What NOT to Use
Avoid broad-spectrum antibiotics unless specifically indicated:
- Extended-spectrum macrolides (azithromycin) show no superior efficacy compared to penicillin 1, 6
- Fluoroquinolones are inappropriate for routine pharyngitis 7
- In France, 8% of Group A Streptococcus strains are now resistant to macrolides, and 60% to tetracyclines 4
- Broader-spectrum agents risk disrupting oropharyngeal ecology and promoting resistance 1, 4
Duration of Treatment
10 days remains the recommended duration for penicillin therapy:
- Shorter courses (3-5 days) show inferior outcomes for symptom resolution 1
- A 7-day course is superior to 3 days but still inferior to 10 days 1
- The traditional 10-day regimen maximizes bacterial eradication, though the primary goal is now symptom relief rather than complication prevention in developed countries 1
Critical Pitfalls to Avoid
Do not prescribe antibiotics empirically without clinical assessment: Use Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) to stratify risk 2, 3
Do not use erythema alone as justification: Pharyngeal erythema is present in both viral and bacterial pharyngitis and does not distinguish between them 8
For persistent sore throat (>2 weeks): This is atypical and demands evaluation for non-infectious causes (malignancy, GERD) rather than empiric antibiotics, as simple pharyngitis resolves within one week in >80% of cases 9
Delayed prescribing is a valid strategy: For patients with 3-4 Centor criteria, consider giving a prescription to fill only if symptoms worsen or fail to improve within 48 hours 1
Symptomatic Management
Always offer analgesics regardless of antibiotic use: