What is the recommended treatment for a patient with a negative Group A Streptococcus (GAS) test but persistent sore throat?

Management of Sore Throat with Negative Strep Test

For a patient with a negative strep test, antibiotics should be withheld and treatment should focus exclusively on symptomatic relief with analgesics such as ibuprofen or acetaminophen. 1

Diagnostic Interpretation by Age Group

Adults

• A negative rapid antigen detection test (RADT) alone is sufficient to rule out Group A Streptococcal (GAS) pharyngitis in adults—no backup throat culture is needed. 1, 2
• The specificity of RADT is ≥95%, making false positives rare, while sensitivity is 80-90%. 2, 3
• Adults have only 5-10% prevalence of GAS pharyngitis and extremely low risk of acute rheumatic fever, making the risk-benefit ratio strongly favor withholding antibiotics. 2, 3

Children and Adolescents

• In children and adolescents, a negative RADT requires confirmation with a throat culture before making final treatment decisions. 1, 2, 3
• RADTs have 80-90% sensitivity in children, meaning they miss 10-20% of true infections. 2, 3
• Treatment can be safely initiated within 9 days of symptom onset if the culture returns positive, which still effectively prevents acute rheumatic fever. 2, 3
• Children under 3 years should not be tested for GAS pharyngitis except when risk factors exist (such as an older sibling with confirmed GAS infection), as the condition is rare in this age group. 1, 2

Recommended Symptomatic Treatment

First-Line Analgesics

• Ibuprofen or acetaminophen (paracetamol) are the recommended first-line agents for pain relief and fever control. 1
• Ibuprofen and diclofenac are slightly more effective than acetaminophen for pain relief, though both are safe for short-term use. 1
• Ibuprofen shows the best benefit-risk profile among systemic analgesics. 4
• Aspirin should be avoided in children due to the risk of Reye syndrome. 1

Adjunctive Measures

• Topical anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg lozenges) can provide temporary symptomatic relief. 1, 4
• Lozenges represent a choking hazard for young children and should be avoided in this population. 1
• Warm salt water gargles are commonly used but lack robust evidence. 1

What NOT to Use

• Corticosteroids are not recommended despite minimal evidence of symptom reduction (approximately 5 hours), given the self-limited nature of pharyngitis and potential adverse effects. 1
• Local antibiotics or antiseptics should not be recommended due to lack of efficacy data and the predominantly viral etiology. 4

Clinical Context and Expected Course

• Most cases of acute pharyngitis are viral (65-80% of cases) and self-limiting, with mean symptom duration of 7 days. 5
• Antibiotics shorten sore throat duration by only 1-2 days, with a number needed to treat of 6 at 3 days and 21 at 1 week. 2, 3
• The primary justification for treating confirmed streptococcal pharyngitis is prevention of acute rheumatic fever, peritonsillar abscess, and spread during outbreaks—not symptom relief. 2, 3
• Antibiotics do not prevent post-streptococcal glomerulonephritis. 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics based on clinical appearance alone (such as tonsillar exudates or white patches), as these features overlap broadly between bacterial and viral causes. 1, 2
• Up to 70% of patients with sore throats receive unnecessary antibiotic prescriptions, while only 20-30% actually have GAS pharyngitis. 2
• Do not test or treat asymptomatic household contacts, even with a history of recurrent infections—this is not recommended and does not reduce subsequent GAS pharyngitis incidence. 1, 2
• Do not perform routine follow-up throat cultures or RADTs after completing treatment in asymptomatic patients, as positive tests may simply reflect carrier status rather than active infection. 1

When to Reconsider the Diagnosis

• If symptoms persist beyond 3-4 days or worsen significantly, consider suppurative complications (peritonsillar abscess, retropharyngeal abscess) or alternative diagnoses (infectious mononucleosis, epiglottitis). 2
• Clinical features strongly suggesting viral etiology include cough, rhinorrhea, hoarseness, conjunctivitis, and oral ulcers—these patients should not have been tested in the first place. 1, 2
• Consider Epstein-Barr virus infectious mononucleosis in patients with severe pharyngitis, tonsillar exudate, and white patches, particularly if accompanied by fatigue and splenomegaly. 2

Special Populations

Chronic GAS Carriers

• Chronic pharyngeal carriers have GAS present but no active immunologic response (no rising anti-streptococcal antibody titers). 1
• As many as 20% of asymptomatic school-age children may be GAS carriers during winter and spring. 1
• Carriers do not require antimicrobial therapy, as they are unlikely to spread GAS and are at little or no risk for developing complications. 1
• Patients with recurrent positive tests may be chronic carriers experiencing intercurrent viral infections rather than repeated true GAS infections. 1