What is the appropriate management for a 12-year-old child presenting with a severe sore throat?

Management of Severe Sore Throat in a 12-Year-Old

Perform a rapid antigen detection test (RADT) immediately, and if negative, obtain a backup throat culture before making any treatment decision—antibiotics should only be prescribed if Group A Streptococcus is confirmed by either test. 1

Diagnostic Strategy

The 12-year-old falls into the high-risk age group (5-15 years) where Group A Streptococcus (GAS) accounts for 20-30% of pharyngitis cases, making laboratory confirmation mandatory before prescribing antibiotics. 2, 3

Two-Step Testing Algorithm for Children

• Step 1: Perform RADT first—it has ≥95% specificity, making false positives rare. 1
• Step 2: If RADT is positive, proceed directly to antibiotic treatment without culture confirmation. 1
• Step 3: If RADT is negative, you must obtain a backup throat culture because RADT sensitivity is only 80-90% in children, missing 10-20% of true infections. 1, 4
• Treatment can be initiated within 9 days of symptom onset and still prevent acute rheumatic fever, so waiting for culture results (24-48 hours) is safe and appropriate. 1

When NOT to Test

• Do not test if the child has clear viral features: cough, rhinorrhea, hoarseness, conjunctivitis, or oral ulcers—these strongly indicate viral etiology. 1, 2
• The presence of cough essentially rules out streptococcal pharyngitis. 1

First-Line Antibiotic Treatment (Only if GAS Confirmed)

Penicillin V or amoxicillin for 10 days is the definitive first-line regimen. 1

Specific Dosing

• Penicillin V: 250 mg orally 2-3 times daily (child <27 kg) or 500 mg 2-3 times daily (child ≥27 kg) for 10 days. 1
• Amoxicillin: 50 mg/kg once daily (maximum 1 gram) for 10 days—preferred for better palatability and once-daily dosing. 1
• Benzathine penicillin G (IM): 600,000 units single dose (<27 kg) or 1,200,000 units (≥27 kg)—use only if adherence concerns exist. 1

The 10-day duration is non-negotiable—shorter courses lack evidence for adequate GAS eradication and rheumatic fever prevention. 1, 3

Penicillin-Allergic Patients

• Non-anaphylactic allergy: First-generation cephalosporin (cephalexin or cefadroxil) for 10 days. 1
• Anaphylactic or immediate-type hypersensitivity:
  • Clindamycin 20 mg/kg/day divided three times daily (max 1.8 g/day) for 10 days, or 1
  • Azithromycin 12 mg/kg once daily (max 500 mg) for 5 days, or 1
  • Clarithromycin 15 mg/kg/day divided twice daily for 10 days. 1

Symptomatic Management (Regardless of Etiology)

• Ibuprofen or acetaminophen for pain and fever relief—these are the most effective symptomatic treatments. 1, 5
• Avoid aspirin in children due to Reye syndrome risk. 6
• Throat lozenges may provide additional comfort. 1

Management When Tests Are Negative

Withhold all antibiotics and provide only symptomatic care—the vast majority of negative-test cases are viral and self-limiting. 1

• Most viral pharyngitis resolves within 7 days without treatment. 6
• Antibiotics offer no benefit for viral pharyngitis and contribute to resistance, side effects, and unnecessary costs. 1, 2

Critical Pitfalls to Avoid

• Do NOT prescribe antibiotics based on clinical appearance alone—even severe exudates and white patches occur with viral infections. 1
• Do NOT skip the backup culture after a negative RADT in children—this is the single most common error leading to missed streptococcal infections. 1, 4
• Do NOT test or treat asymptomatic household contacts—up to one-third are carriers, and prophylaxis does not reduce subsequent infection rates. 1
• Do NOT perform routine follow-up testing after completing therapy in asymptomatic patients—positive results often reflect carrier state rather than treatment failure. 1
• Do NOT use abbreviated antibiotic courses—the full 10-day regimen is required for adequate GAS eradication and rheumatic fever prevention. 6, 3

Red Flags Requiring Urgent Evaluation

Immediately evaluate for complications if the child develops:

• Difficulty swallowing or drooling
• Neck tenderness or swelling
• Unilateral tonsillar swelling with uvular deviation
• "Hot-potato" voice

These may indicate peritonsillar abscess, retropharyngeal abscess, or other suppurative complications requiring imaging and specialist consultation. 6