What is the recommended evaluation and management for a patient presenting with sore throat, fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and no cough?

Evaluation and Management of Acute Pharyngitis with Centor Criteria Features

This patient meets all 4 modified Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) and requires immediate testing for Group A Streptococcus with a rapid antigen detection test (RADT) or throat culture—do not treat empirically without microbiological confirmation. 1, 2

Initial Clinical Assessment

Determine Likelihood of Bacterial vs. Viral Infection

When to test for GAS:

• Test when the patient presents with sore throat and fever and lacks viral features (no cough, rhinorrhea, hoarseness, or conjunctivitis). 1, 2
• This patient's presentation—fever, tonsillar exudates, tender anterior cervical adenopathy, and absence of cough—strongly suggests bacterial pharyngitis and warrants testing. 1, 3

When NOT to test:

• Do not test patients with obvious viral features: cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oral ulcers/vesicles. 1, 2
• Do not test children under 3 years unless specific risk factors exist (e.g., household contact with confirmed GAS). 1, 2

Modified Centor Criteria Application

The modified Centor criteria include four elements, each worth one point: 1

• Fever by history
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough

Critical caveat: The Centor criteria have low positive predictive value (only 35-50% of patients meeting all criteria are GAS-positive), so they identify who needs testing rather than who should receive antibiotics. 1, 2 Patients with fewer than 3 Centor criteria do not need testing. 1

Diagnostic Testing Strategy

Microbiological Confirmation is Mandatory

RADT as first-line test:

• Perform RADT immediately; a positive result is diagnostic and warrants treatment. 2, 3
• RADT has 90-96% specificity and 79-88% sensitivity. 2

Backup throat culture requirements:

• In children and adolescents, a negative RADT must be followed by throat culture because of lower sensitivity and the risk of missing rheumatic fever cases. 1, 2
• In adults, backup culture after negative RADT is optional given low rheumatic fever risk. 2

Never treat empirically: Even experienced clinicians cannot reliably distinguish bacterial from viral pharyngitis based on clinical features alone—microbiological confirmation prevents unnecessary antibiotic use in the 50-70% of cases that are viral. 1, 2

Treatment Algorithm

If GAS is Confirmed (Positive RADT or Culture)

First-line antibiotic therapy:

• Penicillin V or amoxicillin for 10 days is the treatment of choice based on proven efficacy, narrow spectrum, safety, low cost, and zero documented resistance. 1, 2, 4
• The 10-day duration is essential for bacterial eradication and prevention of acute rheumatic fever. 2

For penicillin-allergic patients:

• Non-anaphylactic allergy: Use a narrow-spectrum cephalosporin (cefadroxil or cephalexin) for 10 days. 1, 2
• True anaphylactic allergy: Use clindamycin (approximately 1% GAS resistance in the U.S.) or a macrolide (5-8% resistance; use with caution). 2

Avoid these antibiotics:

• Do not use broad-spectrum cephalosporins (cefdinir, cefixime, cefpodoxime) when narrow-spectrum options are available—they promote resistance and cost more. 2
• Do not use fluoroquinolones, tetracyclines, or sulfonamides for GAS pharyngitis. 2

If Testing is Negative or Viral Features Predominate

Supportive care only:

• Provide analgesics (acetaminophen or NSAIDs; avoid aspirin in children due to Reye syndrome risk). 2
• Recommend adequate hydration, warm saline gargles, topical anesthetics, and rest. 1, 2
• Do not prescribe antibiotics—they provide no benefit for viral pharyngitis and increase adverse events including diarrhea, dermatitis, C. difficile colitis, and antibiotic resistance. 1

Treatment Goals and Outcomes

Primary objectives of antibiotic therapy for confirmed GAS: 1, 2

• Prevention of acute rheumatic fever (the most critical outcome)
• Prevention of suppurative complications (peritonsillar abscess, cervical lymphadenitis, mastoiditis)
• Rapid reduction in infectivity to limit transmission
• Improvement in clinical symptoms (antibiotics shorten symptom duration by only 1-2 days) 5

Red Flags Requiring Urgent Evaluation

Evaluate immediately for serious throat infections if the patient has: 1

• Difficulty swallowing or drooling
• Neck tenderness or swelling
• Respiratory distress
• Signs of peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome

Lemierre syndrome consideration:

• Fusobacterium necrophorum causes approximately 10-20% of endemic pharyngitis in adolescents and can lead to life-threatening Lemierre syndrome. 1
• Maintain high suspicion in adolescents and young adults with severe pharyngitis; urgent diagnosis and treatment are necessary. 1

Common Pitfalls to Avoid

• Do not treat based on clinical impression alone—this leads to unnecessary antibiotics in 50-70% of cases because viral causes predominate. 2, 4
• Do not assume all exudative pharyngitis is bacterial—viruses (adenovirus, Epstein-Barr virus) frequently produce tonsillar exudates. 2
• Do not test or treat asymptomatic household contacts—positive results often represent carriage rather than active infection. 1, 6
• Do not perform routine post-treatment testing unless symptoms persist or recur. 2
• Recognize GAS carriers—up to 20% of school-age children may be asymptomatic carriers; a positive test in a patient with primarily viral symptoms may reflect carriage, not acute infection. 2