Treatment for Acute Pharyngitis Without Exudates
For a healthy adult with mild pharyngeal erythema, uvular swelling, and no exudates, antibiotics are not indicated—treat symptomatically with ibuprofen or acetaminophen for pain relief. 1, 2
Clinical Assessment and Risk Stratification
The absence of exudates, combined with oropharyngeal redness alone, suggests a viral etiology rather than bacterial pharyngitis. 1 Apply the Centor criteria to assess streptococcal risk:
- Tonsillar exudates (absent = 0 points)
- Tender anterior cervical adenopathy (not mentioned = 0 points)
- Fever by history (not mentioned = 0 points)
- Absence of cough (not mentioned = unknown)
With fewer than 3 Centor criteria, testing for Group A Streptococcus is not warranted, and antibiotics should not be prescribed. 1
Recommended Symptomatic Treatment
First-Line Analgesics
- Ibuprofen is the preferred first-line systemic analgesic, showing slightly superior efficacy compared to acetaminophen, particularly after 2 hours of administration. 2, 3
- Acetaminophen (paracetamol) is an acceptable alternative with equivalent safety for short-term use. 2
- Both medications have a low risk of adverse effects when used according to directions. 2
Dosing Recommendations
- Ibuprofen 400 mg provides faster onset of relief (median 24 minutes) compared to acetaminophen 1000 mg (median 30 minutes). 4
- Continue analgesic therapy as needed for symptom control over the typical 7-day course of viral pharyngitis. 1, 5, 6
What NOT to Do
Avoid these common pitfalls:
- Do not prescribe antibiotics empirically without confirmed streptococcal infection—this presentation lacks features suggestive of bacterial pharyngitis. 1
- Do not use local antibiotics or antiseptics, as they lack efficacy data and are not recommended for predominantly viral sore throats. 2, 7
- Do not prescribe corticosteroids for mild presentations—they are only considered for severe cases (3-4 Centor criteria) in conjunction with antibiotics. 2
- Do not recommend zinc gluconate, herbal remedies, or acupuncture due to conflicting efficacy data or lack of reliable evidence. 2
When to Consider Testing or Antibiotics
Only test for Group A Streptococcus if the patient develops:
- Persistent fever
- Tonsillopharyngeal exudates
- Tender anterior cervical adenopathy
- Absence of viral symptoms (cough, rhinorrhea, hoarseness, oral ulcers) 1
If testing becomes indicated and is positive, penicillin or amoxicillin remains first-line treatment for 10 days. 1 However, even with confirmed streptococcal pharyngitis, antibiotics only shorten symptom duration by 1-2 days, with a number needed to treat of 6 at 3 days. 1
Expected Clinical Course
Reassure the patient that viral pharyngitis is self-limited, with most cases resolving within less than 1 week. 1 Symptom duration typically ranges from 1 to 7 days, with over 80% achieving complete resolution by day 7. 8, 9