Prednisone for Strep Pharyngitis with Enlarged Tonsils
Corticosteroids are not recommended as adjunctive therapy for streptococcal pharyngitis, even when tonsils are markedly enlarged. 1
Why Steroids Are Not Recommended
The Infectious Diseases Society of America explicitly advises against using corticosteroids in Group A streptococcal pharyngitis because they do not address the primary treatment goals: preventing acute rheumatic fever and suppurative complications such as peritonsillar abscess, cervical lymphadenitis, and mastoiditis. 1 These outcomes require bactericidal antibiotics to eradicate Group A Streptococcus, not anti-inflammatory agents. 1
The cornerstone of treatment remains appropriate antibiotic therapy for a full 10-day course, which achieves maximal pharyngeal bacterial eradication and prevents both acute rheumatic fever and suppurative complications. 2, 1
Appropriate Management Instead
First-Line Antibiotic Therapy
Penicillin V (250 mg four times daily or 500 mg twice daily in adults; 250 mg twice or three times daily in children) for 10 days remains the drug of choice due to proven efficacy, narrow spectrum, safety, and zero documented resistance worldwide. 2, 3
Amoxicillin (50 mg/kg once daily, maximum 1000 mg; or 25 mg/kg twice daily, maximum 500 mg per dose) for 10 days is equally effective and often preferred in children due to better palatability. 2, 3
Benzathine penicillin G (600,000 units IM for patients <27 kg; 1,200,000 units IM for patients ≥27 kg) as a single dose ensures compliance when adherence to oral therapy is questionable. 2, 3
For Penicillin-Allergic Patients
Non-immediate (delayed) penicillin allergy: First-generation cephalosporins such as cephalexin (500 mg twice daily for 10 days in adults; 20 mg/kg twice daily, maximum 500 mg per dose, for 10 days in children) are preferred, with only 0.1% cross-reactivity risk. 1, 3
Immediate/anaphylactic penicillin allergy: Clindamycin (300 mg three times daily for 10 days in adults; 7 mg/kg three times daily, maximum 300 mg per dose, for 10 days in children) is the preferred alternative, with approximately 1% resistance among U.S. Group A Streptococcus isolates. 1, 3
Symptomatic Relief
Acetaminophen or NSAIDs (such as ibuprofen) should be offered for moderate to severe throat pain, fever, or systemic discomfort. 1, 3
Aspirin must be avoided in children due to the risk of Reye syndrome. 1, 3
When to Reassess
Re-evaluate patients 48–72 hours after initiating antibiotic therapy if marked throat swelling persists or symptoms worsen. 1 Lack of improvement may signal suppurative complications such as peritonsillar or parapharyngeal abscess, which require urgent imaging (contrast-enhanced CT) and may necessitate drainage procedures or intravenous antibiotics—not corticosteroids. 1
Critical Pitfalls to Avoid
Do not prescribe corticosteroids solely for prominent tonsillar enlargement, as they provide no benefit in preventing complications and do not address the underlying bacterial infection. 1
Do not shorten the antibiotic course below 10 days (except azithromycin's 5-day regimen), as this dramatically increases treatment failure rates and the risk of acute rheumatic fever. 1, 3
Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions due to up to 10% cross-reactivity risk. 1, 3