How should I manage a healthy adult or adolescent with acute sore throat, fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and no recent antibiotic use?

Management of Acute Sore Throat in a Healthy Adult or Adolescent with High-Probability Streptococcal Features

This patient meets 4 out of 4 Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, no cough) and should undergo rapid antigen detection testing (RADT) for Group A Streptococcus; if positive, treat with penicillin V 250 mg twice or three times daily for 10 days. 1

Step 1: Apply the Modified Centor Criteria to Determine Testing Strategy

Your patient scores 4 points on the Centor criteria: 1

• Fever by history: +1 point
• Tonsillar exudates: +1 point
• Tender anterior cervical lymphadenopathy: +1 point
• Absence of cough: +1 point

With a Centor score of 4, the probability of Group A Streptococcus (GAS) pharyngitis is 51-53%, making testing strongly recommended before prescribing antibiotics. 2 Patients with 3-4 Centor criteria warrant microbiological confirmation with rapid antigen detection test or throat culture. 1

Step 2: Perform Rapid Antigen Detection Testing (RADT)

• Order a rapid antigen detection test immediately. A positive RADT is diagnostic for GAS pharyngitis and requires no further confirmation. 2
• If the RADT is negative in an adolescent, obtain a backup throat culture because rapid tests have lower sensitivity in this population. 2 In adults, backup culture after negative RADT is not routinely required. 2
• Do not prescribe empiric antibiotics without microbiological confirmation, even with high clinical suspicion, as this contributes to unnecessary antibiotic use. 1, 3

Step 3: Antibiotic Treatment if GAS is Confirmed

First-line therapy: Penicillin V 250 mg orally twice or three times daily for 10 days. 1, 3 The full 10-day course is essential; shorter regimens lack sufficient evidence for GAS eradication. 1, 4

Alternative Regimens for Penicillin Allergy:

• For non-anaphylactic penicillin allergy: First-generation cephalosporin 3
• For anaphylactic penicillin allergy: Clindamycin, clarithromycin, or azithromycin 3
• Important caveat: Significant resistance to azithromycin and clarithromycin exists in some U.S. regions, making these less reliable alternatives. 3

Why Penicillin Remains First-Line:

• GAS remains exquisitely sensitive to penicillin in vitro with no documented resistance. 4
• Antibiotics shorten symptom duration by 1-2 days, with number needed to treat of 6 at day 3 and 21 at day 7. 1
• The primary goal is preventing acute rheumatic fever, peritonsillar abscess, and reducing transmission. 1, 4

Step 4: Symptomatic Management for All Patients

Regardless of antibiotic decision, provide analgesic therapy: 1

• Ibuprofen or acetaminophen (paracetamol) are strongly recommended as the most effective symptomatic treatments. 1, 2
• Throat lozenges may provide additional relief. 1
• Avoid aspirin in adolescents due to Reye syndrome risk. 2

Corticosteroids are not routinely recommended for GAS pharyngitis, though they can be considered in adults with severe presentations (3-4 Centor criteria) when used in conjunction with antibiotics. 1 However, the evidence does not strongly support routine use.

Step 5: Red Flags Requiring Urgent Evaluation

If the patient develops any of the following, immediately evaluate for life-threatening complications: 1, 2

• Difficulty swallowing or drooling
• Neck tenderness or swelling
• Trismus (inability to open mouth)
• Unilateral tonsillar swelling with uvular deviation (suggests peritonsillar abscess)
• "Hot potato voice"

These features suggest peritonsillar abscess, retropharyngeal abscess, epiglottitis, or Lemierre syndrome, which require imaging and specialist consultation. 1, 2

Special Consideration for Adolescents:

Fusobacterium necrophorum causes 10-20% of endemic pharyngitis in adolescents and can lead to Lemierre syndrome (suppurative thrombophlebitis of the internal jugular vein). 1 Remain vigilant for severe pharyngitis that worsens despite appropriate treatment in this age group. 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically based on clinical features alone, even with 4/4 Centor criteria—over 60% of adults with sore throat receive unnecessary antibiotics. 1, 5
• Do not use shorter antibiotic courses (e.g., 5 days) with penicillin; the 10-day regimen is required for adequate GAS eradication. 1, 4
• Do not test or treat asymptomatic household contacts unless specific outbreak circumstances exist. 2
• Do not perform post-treatment testing in asymptomatic patients, as this may detect carriers rather than active infection. 2
• Remember that up to 20% of asymptomatic adolescents may be GAS carriers during winter/spring, so a positive test in someone with viral symptoms (cough, rhinorrhea, conjunctivitis) likely represents carriage, not active infection. 2

Expected Clinical Course and Follow-Up

• Streptococcal pharyngitis symptoms resolve within 3-4 days even without antibiotics, though throat soreness may persist 1-2 days longer compared to antibiotic treatment. 5
• Patients with worsening symptoms after 48-72 hours of appropriate antibiotic therapy or symptoms lasting 5 days after treatment initiation should be reevaluated for complications or alternative diagnoses. 3
• Most viral sore throats resolve within 7 days without treatment. 5