Symptomatic Treatment for Viral Pharyngitis
For a patient with a negative streptococcal test, offer ibuprofen or acetaminophen as first-line analgesics for pain relief, along with throat lozenges, and reassure that symptoms typically resolve within one week without antibiotics. 1
Recommended Analgesic Therapy
Ibuprofen or acetaminophen are the evidence-based first-line treatments for viral sore throat, with moderate strength of evidence supporting their use for symptom relief. 1
NSAIDs (such as ibuprofen) or acetaminophen can help reduce pain and are specifically recommended by the American College of Physicians for patients with pharyngitis. 2
Throat lozenges provide additional symptomatic relief and should be offered alongside analgesics. 2, 1
Aspirin is an acceptable alternative in adults but should be avoided in children due to the risk of Reye syndrome. 2
Adjunctive Measures
Salt water gargles and viscous lidocaine are often used in clinical practice for topical pain relief, though there are limited data examining these approaches. 2
The antihistamine the patient is already taking at night may help with any post-nasal drip that could be contributing to throat irritation, and continuing it at bedtime is appropriate. 1
What NOT to Prescribe
Antibiotics should be withheld entirely when the rapid strep test is negative, as the infection is overwhelmingly viral and self-limited; antibiotics provide no clinical benefit and expose patients to adverse effects. 1
Even when strep is present, antibiotics only shorten sore throat duration by 1-2 days, with a number needed to treat of 6 at 3 days and 21 at 1 week—a modest benefit that does not apply to viral pharyngitis. 2
Systemic corticosteroids are not recommended for routine management of uncomplicated viral pharyngitis. 1
Zinc gluconate, herbal remedies, and acupuncture lack sufficient evidence of benefit and are not routinely recommended. 1
Patient Counseling
Reassure the patient that the typical course of a sore throat is less than 1 week and that antibiotics are not needed because they do little to alleviate symptoms in viral infections and may have adverse effects. 2
Patients should understand that a negative rapid strep test has ≥95% specificity, making bacterial infection extremely unlikely. 1
Advise the patient to return if symptoms persist beyond 3-4 days or worsen significantly, as this may suggest suppurative complications or alternative diagnoses. 1
Common Pitfalls to Avoid
Do not prescribe antibiotics based on clinical appearance alone (such as pharyngeal erythema or exudates), as these findings occur in both viral and bacterial infections. 1
Treating without laboratory confirmation leads to overuse of antibiotics, with up to 70% of sore throat patients receiving unnecessary prescriptions when only 20-30% actually have streptococcal pharyngitis. 1
Do not test or treat asymptomatic household contacts, as up to one-third may be asymptomatic carriers and prophylactic treatment does not reduce subsequent infection rates. 1