When to start antibiotics for pharyngitis ?

Pharyngitis is one of the most common reason for outpatient consultation, yet is an uncommon topic
for clinical research . Diagnosis of the condition is usually straight forward, but to decide on antibiotic
treatment is often challenging . Frequently clinicians tend to overtreat their patients with
antibiotics.But blaming the clinicians is not the solution since complications of untreated
streptococcal throat infections is well known in India. In this document I have attempted to give a
practical method to decide on antibiotic therapy in patients with pharyngitis.This guideline is applicable
to individuals in the community who are not immunosuppresive [ disease or drug induced] , are not
involved in health care [medical and paramedical students, doctors,nurse,ward boy,midwife,etc ] and
were not exposed to an hospital environment in the previous 4 weeks ,since the spectrum of infecting
organisms in these individuals are different.

Literature indicates that pharyngitis are most often caused by viruses [ rhinovirus, adenovirus, Epstein-
barr virus,etc] and less often by bacteria [ Group A Beta-hemolytic Streptococci, H.Influenza,etc].
Antibiotic therapy is likely to help bacterial pharyngitis. But , how can we differentiate bacterial and
viral pharyngitis?.

Unfortunately no single clinical feature differentiates bacterial from viral pharyngitis ,but a
combination of features may be used to differentiate them. Centor identified that when patients had
three of the following four features i) fever ii)tonsillar or pharyngeal exudates iii) tender anterior
cervical lymphadenopathy and iv)absence of cough , they have a 70% probability of streptococcal
pharyngitis. Antibiotic therapy will probably benefit them. While, if they have none or one of the
criteria, then the probability of streptococcal pharyngitis is less than 10%.
Coming back to our question,"When should we prescribe antibiotics to a patient with pharyngitis?", the
answer will be :

1. Prescribe antibiotics in patients having 3 of the 4 Centor criteria. A five day course of
amoxycillin or erythromycin, a three day course of azithromycin or a three day course of
amoxycillin-clavulinic acid are all equally effective.

2. Do not prescribe antibiotics to patients who have less than 2 of the 4 Centor criteria

3. In patients who have 2 of the 4 Centor criteria, a decision is difficult to make. I would suggest
to delay antibiotic initiation, but ask the patient to initiate them if symptoms are worsening or if
fresh symptoms occur

Dr. M. Emmanuel Bhaskar

Specialist in Internal Medicine

Chennai , India