What is the most appropriate therapy to prevent complications in a 6‑year‑old child with sore throat, inflamed tonsils, and small anterior cervical lymphadenopathy?

Management of Pharyngitis in a 6-Year-Old Child

Amoxicillin for 10 days (Option B) is the correct answer to prevent complications of Group A Streptococcal pharyngitis, but ONLY after microbiological confirmation with rapid antigen detection test (RADT) or throat culture.

Diagnostic Approach: Testing is Mandatory Before Treatment

You cannot and should not prescribe antibiotics based on clinical presentation alone. Even experienced clinicians cannot reliably distinguish viral from bacterial pharyngitis without testing 1, 2. The clinical features described—sore throat, possible fever, inflamed tonsils without follicles, and small anterior cervical lymph nodes—overlap too broadly between viral and streptococcal causes 1.

When to Test for GAS

This 6-year-old should be tested because 1, 2:

• Age 5-15 years is the peak incidence for GAS pharyngitis 1
• Presence of fever (even if uncertain) and anterior cervical lymphadenopathy are suggestive features 1, 2
• Inflamed tonsils without obvious viral features (no mention of cough, rhinorrhea, hoarseness, or conjunctivitis) 1, 2

Testing Methodology

• Perform RADT first: A positive result is diagnostic and warrants immediate treatment 1, 2
• If RADT is negative in this child, obtain a backup throat culture: This is mandatory in children and adolescents because RADT sensitivity is only 79-88%, and missing GAS risks acute rheumatic fever 1, 2
• Do NOT treat empirically while awaiting culture results unless the child has severe systemic toxicity 1

Why Each Option is Right or Wrong

Option A (Acyclovir) - INCORRECT

Acyclovir has no role in routine pharyngitis management 1. Viral pharyngitis (the most common cause) requires only supportive care—analgesics, hydration, and rest 1, 2. Acyclovir would only be considered for herpes simplex pharyngitis with discrete ulcerative lesions, which is not described here 2.

Option B (Amoxicillin 10 days) - CORRECT (after positive test)

If GAS is confirmed by RADT or culture, amoxicillin 50 mg/kg once daily (max 1000 mg) or 25 mg/kg twice daily (max 500 mg per dose) for 10 days is first-line therapy 1. This regimen:

• Prevents acute rheumatic fever (the primary goal) 1, 3
• Prevents suppurative complications (peritonsillar abscess, cervical lymphadenitis) 1
• Reduces transmission to close contacts 1
• Shortens symptom duration by 1-2 days 1

The full 10-day course is essential to achieve bacterial eradication and prevent rheumatic fever 1, 3. Shorter courses have higher rates of late bacteriological recurrence 4.

Option C (Ceftriaxone 5 days) - INCORRECT

Ceftriaxone is not recommended for routine GAS pharyngitis 1. Broad-spectrum cephalosporins should be avoided when narrow-spectrum options (penicillin/amoxicillin) are available because they are more expensive and promote antibiotic resistance 1, 2. Ceftriaxone might be considered only for treatment failures or when compliance with oral therapy is impossible 1.

Option D (Reassure) - POTENTIALLY CORRECT (if testing is negative)

Reassurance is appropriate ONLY if:

• RADT and backup throat culture are both negative 1, 2
• The child has obvious viral features (cough, rhinorrhea, conjunctivitis) making GAS unlikely 1, 2

In those cases, provide supportive care: acetaminophen or ibuprofen for pain/fever, adequate hydration, and reassurance that symptoms will resolve in 3-7 days 1, 2.

Critical Pitfalls to Avoid

1. Treating without microbiological confirmation leads to unnecessary antibiotic use in 50-70% of cases because viral causes predominate 1, 2

2. Failing to obtain backup throat culture after negative RADT in children misses 10-20% of GAS infections, exposing them to risk of rheumatic fever 1, 2

3. Stopping antibiotics before 10 days increases bacteriological recurrence and may not prevent rheumatic fever 1, 4

4. Testing patients with obvious viral symptoms (cough, rhinorrhea) generates false-positive results due to 10-15% asymptomatic GAS carriage 1, 2

Expected Clinical Course

• Most viral pharyngitis resolves within 3-7 days without treatment 2, 5
• Even confirmed GAS pharyngitis is often self-limiting; antibiotics shorten symptoms by only 1-2 days but are given primarily to prevent complications 1, 5
• If symptoms worsen after 48-72 hours of appropriate antibiotics or persist beyond 5 days, reevaluate for suppurative complications (peritonsillar abscess) 5, 6