Bacterial Pharyngitis Treatment & Management

Updated: Mar 17, 2016
  • Author: Maria A Carrillo-Marquez, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Treatment

Medical Care

Overzealous prescription of antibiotics for pharyngitis has been estimated to cost health payers $1.2 billion annually. [42] Therefore, treatment of GABHS pharyngitis should be initiated only after confirmation with a RADT or throat culture. [1] Alternatively, treatment in high-risk patients may be started before throat culture results are available, but antibiotics should be stopped if the culture returns negative results. Even though most cases of GABHS pharyngitis resolve after 3-4 days without treatment, antibiotics decrease the likelihood of local suppurative complications and acute rheumatic fever. Oral antibiotics should be administered for 10 days, although many recent studies show similar efficacy with shorter courses. [43] Antibiotic therapy does not decrease the likelihood of poststreptococcal glomerulonephritis.

Oral penicillin V remains the preferred antibiotic to treat GABHS pharyngitis. [1] Amoxicillin is often prescribed and is an acceptable first-line agent because of its narrow spectrum, the ease of once-daily dosing, and improved palatability, especially for children. Both antibiotics are equally efficacious. [44, 45, 46]

In vitro, no isolate of GABHS has ever been resistant to penicillin. Advantages of oral penicillin include its narrow spectrum, low cost, infrequent adverse effects, and proven track record.

A recent Cochrane meta-analysis evaluating patient outcomes on different antibiotics for group A streptococcal pharyngitis concluded that there is insufficient data to show clinically meaningful differences between antibiotics for GABHS tonsillopharyngitis and that, considering the low cost and absence of resistance, penicillin can still be recommended as first choice. [47] Nevertheless, GABHS is sensitive to many other antibiotics, which can be considered as alternative choices based on numerous factors.

Circumstances dictating that a choice other than penicillin V should be used

Compliance: Oral penicillin requires multiple daily doses and a 10-day course. In patients unlikely to adhere to this regimen, one dose of intramuscular benzathine penicillin provides a depot that releases medication over the course. Recent reports have supported the use of once-daily amoxicillin and verified its noninferiority to twice-daily penicillin [44] or twice-daily amoxicillin. [45] Azithromycin, cefdinir, and cefpodoxime may all be given in 5-day courses, although none of these medications should not be considered a first-line agent given their extended spectrum and risk for promoting antibiotic resistance. [1, 48, 49] Furthermore, although no differences in treatment outcomes have been found between macrolides and penicillin, children experienced more adverse events with macrolides. [47]

Palatability: Some young children find oral penicillin unpalatable. Taste tests and many doctors’ experiences have shown amoxicillin to be much better tolerated. [50] Amoxicillin’s similar spectrum and low cost make it a reasonable substitute.

Allergy: In patients with an immunoglobulin E (IgE)–mediated penicillin allergy, antibiotics that contain a beta-lactam ring (cephalosporins, amoxicillin) should be used with caution. Although cross-reactivity between penicillin and cephalosporins is probably less than 10%, the risk of anaphylaxis justifies the consideration of other viable agents. [51] In patients with nonanaphylactic reactions to penicillin a first generation cephalosporin (Cephalexin, Cefadroxil) is a treatment alternative. In patients with history of severe or anaphylactic reactions to penicillin, macrolides such as azithromycin, clarithromycin, and erythromycin may be used, although resistance has been reported in the United States [52] and internationally. [53] Clindamycin is also a reasonable alternative in penicillin-allergic patients, as resistance rates remain less than 1% in the United States. [54]

Recurrence: Test of cure is not indicated when pharyngitis symptoms have resolved following treatment. In patients with recurrent symptoms, retreatment with an initial first-line agent (oral penicillin, benzathine penicillin, or a first-generation cephalosporin) is reasonable. Worth noting is the difficulty in differentiating between viral pharyngitis with GABHS carriage and actual GABHS pharyngitis. This becomes even more of an issue in patients with multiple recurrences. Between 5% and 15% of children are asymptomatic carriers during seasons when GABHS pharyngitis is most prevalent. [55] A positive test result during a time of wellness may indicate GABHS carriage. When multiple recurrences are believed to be due to GABHS infection, clindamycin or amoxicillin/clavulanic acid is indicated. [1]

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Surgical Care

In rare cases, pharyngitis spreads to adjacent structures and forms abscesses. In these cases, a drainage procedure performed by an interventional radiologist or otolaryngologist should be considered.

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Consultations

An otolaryngologist should be consulted for local suppurative complications such as peritonsillar abscess and mastoiditis. Tonsillectomy may be considered in recurrent GABHS infection. [56, 57]

An infectious diseases expert may be consulted for patients with immunocompromising conditions or when an agent other than GABHS (eg, HIV) is suspected or confirmed.

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Diet

Allow a regular diet as tolerated in patients with bacterial pharyngitis. Warm liquids may provide symptomatic relief.

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Activity

Encourage rest during the acute illness.

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