Should a 15-year-old patient with stable vitals, high-grade fever, pharyngitis, cold, and cough for one week, on symptomatic treatment, be given antibiotics?

Should Antibiotics Be Given to This 15-Year-Old with Week-Long Pharyngitis and High-Grade Fever?

No, antibiotics should NOT be started empirically in this patient—you must first confirm Group A Streptococcal (GAS) pharyngitis with rapid antigen testing or throat culture before prescribing antibiotics. 1, 2

Immediate Diagnostic Approach

Test before treating. This 15-year-old requires rapid antigen detection testing (RADT) for Group A Streptococcus before any antibiotic decision is made. 1, 3

Clinical Assessment Using Validated Scoring

Apply the McIsaac scoring system to determine testing strategy: 1

• +1 point each for: Temperature ≥38°C, absence of cough, tender anterior cervical adenopathy, tonsillar swelling/exudate, age <15 years
• -1 point for: Age ≥45 years

With a score of 2-3: Obtain rapid antigen test and base antibiotic decision on the result 1

With a score of 4 or higher: Either initiate antibiotics immediately OR obtain culture first 1

The presence of cough in this patient actually decreases the likelihood of streptococcal pharyngitis and suggests a viral etiology. 4, 3

Why Antibiotics Are NOT Indicated Without Confirmation

Most pharyngitis cases (75-90% in adolescents) are viral and do not benefit from antibiotics. 1 The American College of Physicians and CDC explicitly state that antibiotics should be reserved only for confirmed streptococcal pharyngitis. 1

Key Evidence Against Empiric Treatment

• Only 10-25% of adolescents with pharyngitis have GAS infection 1
• Antibiotics provide modest benefit even in confirmed GAS (shortening symptoms by only 1-2 days, with number needed to treat of 6 at 3 days) 1
• Over 60% of adults with sore throat receive unnecessary antibiotics, contributing to resistance 1
• The combination of pharyngitis WITH cough and cold symptoms strongly suggests viral etiology 1, 5

If Testing Confirms GAS Pharyngitis

First-line treatment: Penicillin V or amoxicillin for 10 days 1, 4, 3

For penicillin allergy (non-anaphylactic): First-generation cephalosporins 4, 3

For severe penicillin allergy: Clindamycin or macrolides, though significant resistance to azithromycin and clarithromycin exists in some U.S. regions 3

Current Management While Awaiting Test Results

Symptomatic Treatment (Continue Current Approach)

• Analgesics: NSAIDs are more effective than acetaminophen for pharyngitis-associated pain and fever 4
• Antipyretics: Use only for patient comfort, not to normalize temperature—fever aids immune response 6, 7
• Never aspirin in patients under 16 years due to Reye's syndrome risk 1, 6, 7
• Medicated throat lozenges every 2 hours provide additional relief 4

Red Flags Requiring Immediate Reassessment

This patient needs urgent evaluation if any of the following develop: 1, 2

• Respiratory distress signs: Markedly raised respiratory rate, grunting, intercostal recession, breathlessness with chest signs
• Breathing difficulties beyond simple nasal congestion
• Severe earache suggesting otitis media complication
• Vomiting >24 hours
• Drowsiness or altered consciousness
• Signs of septicemia: Extreme pallor, hypotension

Critical Pitfall to Avoid

The most common error is prescribing antibiotics based solely on symptom duration or severity without microbiologic confirmation. 1, 2 One week of symptoms does NOT automatically indicate bacterial infection—viral pharyngitis can persist 7-10 days. 1 The presence of "cold and cough" symptoms alongside pharyngitis actually argues against streptococcal etiology. 5, 3

Follow-Up Strategy

• Reassess at 48-72 hours if symptoms worsen or fail to improve 2
• If RADT is negative in this adolescent, throat culture is recommended before definitively ruling out GAS 3
• Patients with confirmed GAS who worsen after 5 days of appropriate antibiotics require reevaluation for complications or treatment failure 3