From the Guidelines
Acute pharyngitis, unspecified, should be initially managed with symptomatic relief, and if bacterial pharyngitis is suspected, antibiotic treatment with penicillin or amoxicillin for 10 days is recommended, as stated in the 2012 update by the Infectious Diseases Society of America 1.
Initial Management
Treatment typically involves rest, adequate hydration, and over-the-counter pain relievers such as:
- Acetaminophen (325-650 mg every 4-6 hours, not exceeding 3000 mg daily)
- Ibuprofen (400-600 mg every 6-8 hours with food) Gargling with warm salt water (1/2 teaspoon salt in 8 ounces of water) several times daily can soothe the throat. Throat lozenges, cold beverages, and honey in warm tea may also provide relief.
Bacterial Pharyngitis
Most cases of acute pharyngitis are viral and resolve within 7-10 days without antibiotics. However, if symptoms persist beyond 10 days, worsen after initial improvement, or include high fever (above 101°F/38.3°C), severe pain, difficulty breathing or swallowing, or visible white patches on the tonsils, medical evaluation is necessary to rule out bacterial causes like strep throat.
- Penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents, due to their narrow spectrum of activity, infrequency of adverse reactions, and modest cost 1.
- For penicillin-allergic individuals, alternatives include a first-generation cephalosporin, clindamycin, clarithromycin, or azithromycin 1. It is essential to note that antimicrobial therapy is of no proven benefit as treatment for acute pharyngitis due to bacteria other than group A streptococci, and therefore, it is crucial to exclude the diagnosis of group A streptococcal pharyngitis to prevent inappropriate administration of antimicrobials 1.
Adjunctive Therapy
Adjunctive therapy may be useful in the management of GAS pharyngitis, including the use of an analgesic/antipyretic agent such as acetaminophen or an NSAID for treatment of moderate to severe symptoms or control of high fever associated with GAS pharyngitis, as an adjunct to an appropriate antibiotic 1.
- Aspirin should be avoided in children 1.
- Adjunctive therapy with a corticosteroid is not recommended 1.
From the FDA Drug Label
Pharyngitis/Tonsillitis In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes)
Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS):
Three U. S. Streptococcal Pharyngitis Studies
Azithromycin vs. Penicillin V
EFFICACY RESULTS
Day 14 Day 30
Bacteriologic Eradication:
Azithromycin 323/340 (95%) 255/330 (77%)
Penicillin V 242/332 (73%) 206/325 (63%)
Clinical Success (Cure plus improvement):
Azithromycin 336/343 (98%) 310/330 (94%)
Penicillin V 284/338 (84%) 241/325 (74%)
Azithromycin is effective in the treatment of acute pharyngitis due to Group A β-hemolytic streptococci (GABHS or S. pyogenes), with a clinical success rate of 98% at Day 14 and 94% at Day 30 2.
- Key points:
- Bacteriologic eradication rates: 95% at Day 14 and 77% at Day 30 for azithromycin
- Clinical success rates: 98% at Day 14 and 94% at Day 30 for azithromycin
- Comparison to penicillin V: azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30.
From the Research
Definition and Causes of Acute Pharyngitis
- Acute pharyngitis is a common infectious disease seen in general practitioners' consultations, with viral aetiology being the most common cause 3, 4.
- Among bacterial causes, the main agent is Streptococcus pyogenes or group A β-haemolytic streptococcus (GABHS), which causes 5%-30% of the episodes 3, 4.
- Group A beta-hemolytic streptococcus (GABHS) is the causal agent in approximately 10% of adult cases of pharyngitis 5.
Diagnosis of Acute Pharyngitis
- Clinical assessment scales can help clinicians to better predict suspected bacterial aetiology by selecting patients who should undergo a rapid antigen detection test 3, 4.
- Rapid antigen detection tests and throat cultures can be used with clinical findings to identify the inciting organism 6.
- The Centor criteria, including history of fever, tonsillar exudates, no cough, and tender anterior cervical lymphadenopathy, can be used to clinically screen patients with pharyngitis for the presence of GABHS infection 5.
Treatment of Acute Pharyngitis
- The aim of the treatment is speeding up symptom resolution, reducing the contagious time span and preventing local suppurative and non-suppurative complications 3, 4.
- Penicillin and amoxicillin are the antibiotics of choice for the treatment of pharyngitis 3, 4.
- The association of amoxicillin and clavulanate is not indicated as the initial treatment of acute infection, and macrolides should be reserved for patients allergic to penicillin 3, 4.
- Antibiotic treatment of adult pharyngitis benefits only those patients with GABHS infection, and all patients with pharyngitis should be offered appropriate doses of analgesics and antipyretics, as well as other supportive care 5.