When faced with a sore throat, the clinician’s main task is to identify and treat cases of group A beta-hemolytic streptococcal (GABHS) pharyngitis (Figure 1). All other pathogens can be grouped together because they do not require specific antibiotic treatment. It’s important to remember that the only reason we treat strep throat is to prevent acute rheumatic fever and peritonsillar abscess. Antibiotics remain the standard of care despite evidence showing that both complications (at least in adults who live in developed countries) are exceedingly rare.4
The classic presentation of strep throat infection includes fever, sore throat, headache, abdominal pain, exudative pharyngitis, and cervical adenopathy—without cough, rhinorrhea, or diarrhea, all three of which point toward a viral etiology. However, diagnosis should be based on objective laboratory data from a rapid antigen test or culture. Neither the patient history nor the clinical examination is reliably sensitive or specific.
If GABHS is identified, the treatment of choice remains penicillin. Amoxicillin has an unnecessarily broad spectrum and should be avoided. Use of the macrolides, while effective, has been associated with emerging bacterial resistance. In practice, however, such first-generation cephalosporins as cephalexin (Keflex) are often used. This is because cephalexin has repeatedly led to higher cure rates and lower recurrence rates (perhaps because it has a greater bactericidal effect against intracellular streptococci than penicillin).5 Cephalexin has not, however, translated into lower rates of local suppurative complications or rheumatic fever.
When does a common cold become a sinus infection? This question is usually answered by the patient, who comes into the office seeking treatment for a nagging cold that is getting worse or has not gone away after many days or even weeks. Nevertheless, the evidence shows that the vast majority of sinus infections resolve spontaneously and without specific treatment.6
Consensus guidelines recommend an antibiotic only if the patient fails to improve after 10 days or gets worse after five to seven days. Admittedly, the signs and symptoms that suggest the diagnosis are nonspecific; they include purulent nasal discharge, facial and dental pain, fever, cough, fatigue, anosmia, and ear pressure or fullness. The recommendations are based on the usually self-limited nature of the disease in primary care, difficulties with clinical diagnosis, and the resultant overuse of antibiotics in primary-care settings (as well as the rare incidence of complications).7
If antibiotics are used, most experts still favor amoxicillin, with TMP/SMX as an alternative for patients allergic to penicillin. Such macrolides as azithromycin and clarithromycin are often used but should be avoided because of concerns about rising bacterial resistance. For patients with severe symptoms or a history of antibiotic use in the past three months, consider amoxicillin clavulanate (Augmentin), cefpodoxime, cefuroxime, cefdinir, levofloxacin (Levaquin), or moxifloxacin (Avelox).8