What are empiric antimicrobial recommendations for pharyngitis and the role of steroids in management?

Comment by InpharmD Researcher

The use of empiric antibiotics for pharyngitis is controversial because a vast majority of cases are viral. Clinical tools (i.e., Centor score) may be used to guide empiric antibiotics in the absence of rapid antigen testing and/or cultures; however, observational studies suggest this may still result in unnecessary antibiotics. Some authors still advocate empiric antimicrobial therapy in select patients (e.g., severely ill patients, those at high risk of complications). Corticosteroid use for pharyngitis has been shown to be beneficial for pain management (particularly in viral pharyngitis); however, no benefits were observed on the clinical course (resolution of symptoms, days missed from school/work) for either viral or bacterial etiologies.

Background

Guidance from the Centers for Disease Control and Prevention (CDC) on treating group A Strep pharyngitis recommends antibiotics for any patient (regardless of age) who has a positive rapid antigen test or throat culture. The recommended treatments are penicillin V PO 250 mg QID or 500 mg BID x10 days (250 mg BID or TID x10 in pediatrics), amoxicillin PO 50 mg/kg (maximum 1000 mg) once daily or 25 mg/kg (maximum 500 mg) BID x10 days, or benzathine penicillin G IM 1,200,000 U (600,000 U if <27 kg) x1 dose. In patients with a penicillin allergy, cephalexin, cefadroxil, clindamycin, azithromycin, or clarithromycin can be considered (avoid cephalexin and cefadroxil in patients with immediate type hypersensitivity to penicillin). Empiric therapy is not discussed (likely because this is specific to Group A Streptococcus). There has never been a report of a clinical isolate of group A Strep bacteria that's resistant to penicillin or cephalosporins. However, resistance to azithromycin, clarithromycin, and clindamycin is well known and varies geographically and temporally. [1]

Viral etiologies account for approximately 80% of pharyngitis cases and are typically self-limiting, whereas bacterial infections (particularly those caused by Group A Streptococcus [GAS]; Streptococcus pyogenes) present a greater risk due to potential complications such as acute rheumatic fever, glomerulonephritis, and suppurative sequelae including peritonsillar abscesses. Key clinical scoring systems, including the modified Centor and FeverPAIN criteria, are essential bedside tools to stratify the pretest probability for streptococcal pharyngitis and guide the appropriate use of diagnostics like rapid antigen detection tests (RADTs). While throat cultures remain the diagnostic gold standard with a specificity of 97%-100% and sensitivity of 90%-95%, clinical algorithms should primarily guide initial decisions. The decision to conduct microbiologic testing for a child or adolescent suffering from acute pharyngitis should be informed by both clinical and epidemiological characteristics of their illness. A notable consideration is a history of close contact with confirmed GAS pharyngitis cases or a high community prevalence of GAS infections. Testing is generally unnecessary for patients whose clinical and epidemiological indicators do not suggest GAS as the cause. Using diagnostic studies selectively for GAS not only increases the proportion of true positive results but also helps distinguish between actual infection and mere carrier states. [2], [3]

The modified Centor score was presented with detailed decision thresholds: a score of ≤1 indicates low GAS probability and warrants symptomatic treatment alone, while scores ≥4 suggest an increased risk (up to 53%) and may justify empirical treatment or RADT. The FeverPAIN score showed equivalent or superior utility, particularly in reducing unnecessary antibiotic use, with risk stratifications ranging from 13% to 65% based on total score. For treatment, the preferred antimicrobial regimen for confirmed GAS infections included amoxicillin for 6 to 10 days or a single dose of benzathine penicillin G; cephalexin, clindamycin, or macrolides were reserved for those with penicillin allergy. Notably, the number needed to treat to prevent one sore throat episode at one week was 21. Delayed prescriptions and close follow-up were encouraged in intermediate-risk patients, aligning with UK National Institute for Health and Care Excellence (NICE) guidance, which demonstrated a 27% reduction in antibiotic usage without increased complication rates. This conservative approach may curb resistance and avoid unnecessary treatment in asymptomatic carriers. [2], [3]

Concurrent antibiotic-corticosteroid therapy is generally not indicated for bacterial pharyngitis, as it does not improve pain and might delay recovery. However, steroid use in viral pharyngitis has been found to successfully reduce odynophagia (number needed to treat of 4) without affecting the clinical course. [3]

A 2015 consensus review conducted by Spanish societies of family medicine, infectious diseases, microbiology, pharmacy, and otolaryngology mentions systematic overuse of antibiotics, attributed to overdiagnosis of streptococcal pharyngitis based on non-specific clinical findings, has contributed to increased antimicrobial resistance and unnecessary healthcare costs. The authors recommended using the Centor score to stratify patients by probability of GAS infection. For patients presenting with 2 or more Centor criteria, a rapid antigen detection test (RADT) for GAS was advised as a cost-effective diagnostic method. The RADT demonstrated high specificity (>95%) but variable sensitivity (60%–98%), influencing prescribing behavior; physicians who employed the test prescribed fewer antibiotics. When treatment is indicated based on positive RADT results, the panel endorsed phenoxymethylpenicillin (penicillin V) or amoxicillin as first-line therapy for 8 to 10 days, citing the preserved global susceptibility of GABHS to β-lactams. Macrolides and clindamycin were advised solely in cases of documented penicillin allergy due to growing resistance to macrolides. Amoxicillin-clavulanate was not recommended as initial therapy, given the lack of beta-lactamase production by GAS and its broader spectrum. Additionally, symptomatic management with NSAIDs and topical agents was encouraged; however, the use of corticosteroids remains controversial because their benefit appears to only be for pain relief. [4]

A 2020 Cochrane Review evaluated the effectiveness and safety of corticosteroids as either standalone or adjunctive therapy for sore throat in outpatient settings. This comprehensive analysis incorporated data from nine randomized controlled trials (RCTs) conducted between 1993 and 2017, involving a total of 1,319 participants (950 adults and 369 children), primarily recruited from emergency departments and general practice clinics across five countries. Eight of the nine included trials administered antibiotics to all participants, while one trial incorporated delayed antibiotic prescribin; corticosteroids evaluated included dexamethasone, betamethasone, and prednisone, given via either oral or intramuscular routes. High-certainty evidence demonstrated that corticosteroids significantly increased the likelihood of complete pain resolution at both 24 hours (risk ratio [RR] 2.40; 95% CI, 1.29 to 4.47) and 48 hours (RR 1.50; 95% CI, 1.27 to 1.76), with numbers needed to treat of 5 and 4, respectively. Moderate-certainty evidence showed that corticosteroids accelerated the onset of pain relief by an average of 6 hours (mean difference -5.96 hours; 95% CI, -8.75 to -3.17) and shortened the total duration of pain by approximately 11.6 hours. Notably, no statistically significant differences were observed between groups in terms of adverse events, symptom relapse, or days missed from work or school; however, reporting on adverse outcomes was limited, and only two trials reported pediatric data with inconsistent findings. [5]

A 2017 systematic review and meta-analysis also evaluated 10 RCTs (N= 1,426) on the efficacy and safety of corticosteroids as an adjunctive treatment in patients presenting with sore throat. Eligible trials compared single-dose corticosteroids (most commonly oral dexamethasone up to 10 mg) with placebo or standard care. Patients receiving corticosteroids were twice as likely to experience complete pain relief at 24 hours (RR 2.24; 95% CI 1.17 to 4.29) and had a 50% greater likelihood of being pain-free at 48 hours (RR 1.48; 95% CI 1.26 to 1.75). Corticosteroids also accelerated pain symptom improvement, with a mean 4.8-hour reduction in time to onset of pain relief (95% CI -1.9 to -7.8) and an 11.1-hour reduction in time to complete relief (95% CI -0.4 to -21.8). No significant effect was found on recurrence/relapse of symptoms, days missed from work/school, or the chance of taking antibiotics (in patients given prescription with instructions to take antibiotic if unimproved or worse). [6]

References:

[1] Centers for Disease Control and Prevention. Clinical Guidance for Group A Streptococcal Pharyngitis. Updated March 1, 2024. Accessed March 29. 2025. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
[2] Gerber MA. Pharyngitis. Principles and Practice of Pediatric Infectious Disease. 2008;206-213. doi:10.1016/B978-0-7020-3468-8.50035-3
[3] Sykes EA, Wu V, Beyea MM, Simpson MTW, Beyea JA. Pharyngitis: Approach to diagnosis and treatment. Can Fam Physician. 2020;66(4):251-257.
[4] Cots JM, Alós JI, Bárcena M, et al. Recommendations for Management of Acute Pharyngitis in Adults [Recomendaciones para el manejo de la faringoamigdalitis aguda del adulto]. Acta Otorrinolaringologica (English Edition). 2015;66(3):159-170. doi:10.1016/j.otoeng.2015.05.003
[5] de Cassan S, Thompson MJ, Perera R, et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2020;5(5):CD008268. Published 2020 May 1. doi:10.1002/14651858.CD008268.pub3
[6] Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017;358:j3887. Published 2017 Sep 20. doi:10.1136/bmj.j3887

Literature Review

A search of the published medical literature revealed 2 studies investigating the researchable question:

What are empiric antimicrobial recommendations for pharyngitis and the role of steroids in management?

Level of evidence

B - One high-quality study or multiple studies with limitations  Read more→



Please see Tables 1-2 for your response.


 

Do Hospitalized Adult Patients with Acute Pharyngotonsillitis Need Empiric Antibiotics? The Impact on Antimicrobial Stewardship

Design

Retrospective, single-center, observational, cohort study

N= 290

Objective

To evaluate the necessity of empiric antibiotic use in hospitalized adult patients with acute pharyngotonsillitis and its impact on antimicrobial stewardship

Study Groups

Patients with identified etiology (n= 117)

Patients without identified etiology (n= 173)

Inclusion Criteria

Adult patients (more than 18 years old) admitted with acute pharyngotonsillitis between 2011 and 2021

Exclusion Criteria

Patients with positive influenza rapid test results

Methods

This was a retrospective study from a single center in Taiwan. Consecutive adult patients admitted with acute pharyngotonsillitis were recruited for a complete etiology study, including throat swab for viral isolation and bacterial culture, Group A Streptococcus antigen rapid test, and serology for various viruses and bacteria.

Duration

2011 to 2021

Outcome Measures

Primary: Identification of etiology of acute pharyngotonsillitis

Secondary: Antibiotic prescription rates, application of Modified Centor Criteria

Baseline Characteristics

The etiology of acute pharyngotonsillitis was determined in 117 patients, while 173 patients remained with unidentified etiology despite current diagnostic methods. There were no cases of duplicate viral-viral or viral-bacterial co-infections.

White blood cell counts and C-reactive protein levels showed no significant differences between patients with identified and unidentified etiologies. Among the identified cases, infections included 42 cases of HSV, 26 adenovirus, 16 acute HIV, 12 influenza, 3 parainfluenza, 6 EBV, 1 CMV, 4 enterovirus, 1 VZV, 4 Mycoplasma pneumoniae, 1 Chlamydophila pneumoniae, and 1 Group A Streptococci.

Results

The analysis of the Modified Centor Criteria revealed an average score of 1.38 among patients, with a majority (55%) scoring 0-1 point, 32.5% scoring 2 points, and 12.8% scoring 3 points. Notably, no patient exceeded 4 points, the critical threshold for recommending empirical antibiotic treatment. Despite this, a significant majority of patients (88.9%) were administered antibiotics in the emergency department, and 76.9% received them during hospitalization. The likelihood of receiving antibiotics was markedly higher in patients with HSV pharyngotonsillitis.

Conversely, those with mononucleosis-like syndromes, including EBV, CMV, and acute HIV infections, were less frequently prescribed antibiotics by infectious disease specialists. This trend suggests a possible deviation from guidelines, as patients with non-bacterial infections were less likely to receive unnecessary antibiotics.

Adverse Events

Not specifically reported in the study

Study Author Conclusions

The primary cause of pharyngotonsillitis in hospitalized adult patients was viral infection. Most patients received unnecessary antibiotics, which may lead to bacterial resistance. The Modified Centor Criteria could reduce unnecessary antibiotic use and facilitate antimicrobial stewardship.

Critique

The study highlights the overuse of antibiotics in viral pharyngotonsillitis and suggests the Modified Centor Criteria as a tool for better antimicrobial stewardship. However, the study is limited by its retrospective nature and the inability to identify the etiology in 60% of patients. The use of more advanced diagnostic tools could improve the identification of causative pathogens.

 

References:

Liang CW, Hsiao MC, Kuo SH, et al. Do hospitalized adult patients with acute pharyngotonsillitis need empiric antibiotics? The impact on antimicrobial stewardship. Microorganisms. 2025;13(3):628. doi:10.3390/microorganisms13030628

 

Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults

Design

Prospective, single-center, observational, cohort study

N= 787

Objective

To assess the impact of guideline recommendations and alternative approaches on identification and treatment of Group A Streptococcus (GAS) pharyngitis in children and adults

Study Groups

Children (n= 454)

Adults (n= 333)

Inclusion Criteria

Patients aged 3 to 69 years with acute sore throat attending a family medicine clinic in Calgary, Alberta, from September 1999 to August 2002

Exclusion Criteria

Not specified

Methods

Throat cultures and rapid antigen tests were performed on participants who were treated based on recommendations from the Infectious Diseases Society of America (IDSA), US Centers for Disease Control and Prevention, or the American Society of Internal Medicine (ASIM) guidelines.

The IDSA guidelines recommended antibiotics only for patients with a positive laboratory test (either culture or rapid); by contrast, the ASIM and CDC deviate in adults by using a clinical prediction rule (ie, the Centor score) to determine whom to test or treat directly. These approaches were compared using 6 strategies:

  • Strategy 1 (Standard Approach): Obtain a throat culture in all children and adults with sore throat and treat only those having a positive culture result.
  • Strategy 2 (IDSA/ASIM1): Perform rapid test on all children and treat those having positive results; perform throat culture on those with negative rapid test results and treat any having positive culture results; perform rapid test on all adults and treat those having positive rapid test results without culture confirmation of negative results.
  • Strategy 3 (ASIM2): Treat children per IDSA recommendations. Perform rapid test on all adults having a Centor score of 2 or 3 and treat those with positive rapid test results; treat all adults having a score of 4 or more empirically.
  • Strategy 4 (ASIM3): Treat children per IDSA recommendations. Test no adults and treat those having a Centor score of 3 or 4 empirically.
  • Strategy 5 (Modified Centor Score and Culture Approach): Perform throat culture on all children and adults having a Centor score of 2 or 3 and treat those having positive culture results. Treat those having a score of 4 or more empirically.
  • Strategy 6 (Rapid Test Approach): Perform rapid test on all children and adults and treat those having positive results without culture confirmation of negative results.
Duration

September 1999 to August 2002

Outcome Measures

Primary: Sensitivity and specificity of each strategy for identifying GAS pharyngitis

Secondary: Total antibiotics recommended, unnecessary antibiotic prescriptions

Baseline Characteristics  

Children (n= 454)

Adults (n= 333)
Positive throat culture

34.1%

21.9%
Modified Centor score 4 or 5 67.8%

30.8%

Results   Sensitivity

Specificity

Culture all (strategy 1)

100.0%

100.0%
IDSA/ASIM1 (strategy 2)

92.5%

99.1%
ASIM2 (strategy 3)

93.0%

97.5%
ASIM3 (strategy 4)

92.5%

73.3%
Modified score and culture approach (strategy 5)

100.0%

93.2%
Rapid test (strategy 6)

82.9%

99.1%

Strategy 4 had the highest overall prescribing rate at 45.7%. Within adults, this approach led to 60.7% receiving antibiotics, while children showed a 40.5% prescribing rate with the modified Centor score, higher than the 34.1% for universal culturing.

Unnecessary prescriptions were notably high with these strategies, particularly strategy 4, yielding 18.9% overall and 43.8% in adults. Strategy 5, the modified Centor score, resulted in 4.8% unnecessary prescriptions in children. Strategy 5 also minimized the number of tests per person at 0.87 but required 96.1% of adults to undergo throat cultures.

Strategies 2, 3, and 4 required fewer throat cultures and phone follow-ups, although they necessitated more rapid testing.

Children and adults received more immediate antibiotic treatment using strategies 2, 3, 4, or rapid testing alone (strategy 6) compared to routine throat cultures or the modified Centor score. This suggests that while some strategies optimize immediate treatment, they may also increase unnecessary antibiotic use and testing.

Adverse Events

Not studied

Study Author Conclusions

Guideline recommendations for selective use of throat cultures and antibiotic treatment based on positive rapid test or throat culture results can reduce unnecessary antibiotic use. However, empirical treatment of adults with a Centor score of 3 or 4 is associated with high unnecessary antibiotic use. Strategies incorporating throat culture or confirmation of negative rapid antigen test results are highly sensitive and specific in children.

Critique

The study provides valuable insights into the management of pharyngitis and the impact of different guidelines (which may be outdated in 2025) on antibiotic use. Limitations include the exclusion of patients with a modified Centor score less than 2, which may underestimate the true proportion of missed GAS cases in adults; a modified Centor score was used to approximate the Centor score. Additionally, the study's reliance on rapid tests with varying sensitivity could affect the generalizability of the findings.

 

References:

McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical validation of guidelines for the management of pharyngitis in children and adults [published correction appears in JAMA. 2005 Dec 7;294(21):2700]. JAMA. 2004;291(13):1587-1595. doi:10.1001/jama.291.13.1587