From the Guidelines
Strep pharyngitis is best treated with a 10-day course of oral penicillin V (250-500 mg twice daily for adults, or 250 mg 2-3 times daily for children) or a single intramuscular injection of benzathine penicillin G, as recommended by the Infectious Diseases Society of America 1. For penicillin-allergic patients, alternatives include azithromycin (500 mg on day 1, then 250 mg daily for 4 days) or clindamycin (300 mg three times daily for 10 days) 1. Treatment should begin promptly after diagnosis, which is typically made using rapid antigen detection tests or throat cultures. Complete the full antibiotic course even if symptoms improve to prevent complications like rheumatic fever or kidney inflammation. Supportive care includes:
- Rest
- Adequate hydration
- Saltwater gargles
- Over-the-counter pain relievers like acetaminophen or ibuprofen for fever and throat pain. Strep throat is caused by group A Streptococcus bacteria and spreads through respiratory droplets. Patients are generally no longer contagious after 24 hours of antibiotic therapy and can typically return to work or school at that point. If symptoms worsen or don't improve within 48 hours of starting antibiotics, medical reassessment is recommended 2, 3. It's essential to note that antibiotics may prevent complications from group A streptococcal infection, including acute rheumatic fever, peritonsillar abscess, and further spread of group A Streptococcus in outbreaks 2, 3. However, little evidence supports the prevention of acute glomerulonephritis 2, 3. Antibiotics are not recommended for chronic group A Streptococcus carriers because they are unlikely to spread infection to close contacts and are at little or no risk for complications 2, 3. Tonsillectomy solely to reduce the frequency of group A streptococcal pharyngitis in adults is not recommended 2, 3. Adult patients with sore throat should be offered analgesic therapy, such as aspirin, acetaminophen, nonsteroidal anti-inflammatory drugs, and throat lozenges, which can help reduce pain 2, 3. Salt water, viscous lidocaine, and other mixtures are often used in clinical practice for topical pain relief, but there are few data examining these approaches 2, 3. Patients can be assured that the typical course of a sore throat is less than 1 week and that antibiotics are usually not needed because they do little to alleviate symptoms and may have adverse effects 2, 3. Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis by rapid antigen detection test and/or culture for group A Streptococcus and treat patients with antibiotics only if they have confirmed streptococcal pharyngitis 2, 3.
From the FDA Drug Label
In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum): otherwise the sequelae of streptococcal disease may occur. Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy.
Strep Pharyngitis Treatment:
- The recommended treatment for strep pharyngitis with penicillin (PO) is a ten-day minimum course to eliminate the organism and prevent sequelae of streptococcal disease 4.
- Azithromycin (PO) can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy for pharyngitis/tonsillitis caused by Streptococcus pyogenes 5.
From the Research
Diagnosis of Strep Pharyngitis
- Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4 degrees F (38 degrees C), tonsillar exudates, and cervical adenopathy 6
- Available diagnostic tests include throat culture and rapid antigen detection testing, with throat culture considered the diagnostic standard 6
- The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 6, 7
Treatment of Strep Pharyngitis
- Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness 6
- Amoxicillin is equally effective and more palatable 6, 8
- Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy 6, 9
- Azithromycin is not recommended due to significant resistance in some parts of the United States 8 and lower bacteriologic eradication rates compared to penicillin V 10
Management and Prevention
- Chronic group A beta-hemolytic streptococcus (GABHS) colonization is common despite appropriate use of antibiotic therapy, and chronic carriers are at low risk of transmitting disease or developing invasive GABHS infections 6
- Tonsillectomy is rarely recommended as a preventive measure, with specific thresholds for considering surgery 8
- Nonsteroidal anti-inflammatory drugs and medicated throat lozenges can be used to treat fever and pain associated with GABHS pharyngitis, while corticosteroids are not recommended for routine use 7