Streptococcal pharyngitis
Acute infection of pharynx and tonsils caused by group A beta-hemolytic streptococcus. Antibiotics are given to prevent rheumatic sequelae.
ICD-10 J02.04 drugs
Also known as: Strep throat, GAS pharyngitis
Drugs used for this condition
- AAmoxicillinFirst line · Penicillins with extended spectrumIn group A Streptococcus (GAS) tonsillopharyngitis confirmed by rapid antigen test or culture, Amoxicillin and Penicillin V are equal antibiotics of choice per IDSA 2012 and the Spanish adult consensus (Cots 2015). NICE NG84, ESCMID 2012 and the Spanish paediatric SEIP/AEPap consensus 2020 prefer Penicillin V for its narrow spectrum; in children Amoxicillin is often chosen for the taste of the suspension and once-daily dosing (Lennon 2008 RCT: once-daily Amoxicillin was non-inferior to twice-daily Penicillin V). IDSA 2012 doses: 50 mg/kg once daily (max 1000 mg) or 25 mg/kg twice daily (max 500 mg) for 10 days; adults take these maximum doses. Cochrane 2021 shows that antibiotics shorten symptoms (sore throat on day 3, RR 0.70) and reduce acute otitis media, peritonsillar abscess and rheumatic fever, which is now rare in Europe; with a Centor score of 0–2 no antibiotic is needed (ESCMID 2012). In non-anaphylactic penicillin allergy a first-generation cephalosporin is used, in anaphylaxis a macrolide or Clindamycin. Per the label, Amoxicillin is contraindicated in penicillin allergy and after anaphylaxis to another beta-lactam. If infectious mononucleosis is suspected, which mimics streptococcal tonsillitis, Amoxicillin is not prescribed: it frequently causes a morbilliform rash. Diarrhoea, rash and antibiotic-associated colitis can occur. In pregnancy it is used when benefit outweighs risk; small amounts pass into breast milk. Interactions: Methotrexate (increased toxicity), Allopurinol (more rash), oral anticoagulants (monitor prothrombin time).
- BAzithromycinSecond line · MacrolidesSecond-line for streptococcal pharyngitis, indicated only when the patient has a penicillin allergy. A 5-day course is standard. Penicillin V or amoxicillin remain first-choice per IDSA 2012.
- DBenzydamineAdd-on therapy · Non-steroidal anti-inflammatory agent for topical use in the mouth and throatBenzydamine is often bought «for tonsillitis», with the lozenge taken as a substitute for an antibiotic. It does not work that way. Benzydamine relieves pain and mucosal inflammation, it has no action against group A streptococcus, and the AEMPS ficha técnica ascribes no antimicrobial activity to it. In confirmed streptococcal tonsillopharyngitis the antibiotic decision rests on the clinical picture and a rapid test, while the lozenge remains pain relief on top. The ficha warns separately about the trap: in some patients an ulcer in the mouth or throat signals serious disease, and once symptoms fail to clear in 3 days or fever rises, self-treatment should stop. The danger lies in the delay: while pain is muffled by a lozenge, untreated streptococcus produces peritonsillar abscess and rheumatic fever. If lozenges were offered as treatment for tonsillitis instead of an examination, consider seeking a second opinion.
- DFlurbiprofenAdd-on therapy · Non-steroidal anti-inflammatory drug, propionic acid derivative, for topical throat treatmentA flurbiprofen lozenge is often used instead of a doctor's visit when the throat hurts badly and there is exudate. It has no antimicrobial action: flurbiprofen relieves pain and inflammation while group A streptococcus stays. Worse, the ficha técnica warns directly that an NSAID in this setting masks a developing bacterial infection, and names cases of necrotizing fasciitis during treatment. When streptococcal tonsillopharyngitis is suspected, the decision rests on examination and a rapid test: some patients need an antibiotic, others are not prescribed one, and the analgesic is an add-on here. The rule of thumb is simple: pain worse than an ordinary cold, fever above 38, tonsillar exudate, enlarged neck nodes and no cough – that is a reason to see a doctor rather than buy another pack of lozenges.
How to read tiers A–F
Evidence tiers belong to the drug-indication pair, not to the drug as a whole: the same substance can be A for one condition and F for another.
- AStrong evidence – first or second line in international guidelines
- BRecommended in selected cases
- CStudy data contradict each other
- DBenefit not proven, no documented harm
- FDocumented harm, or risk without benefit