When Does Strep Throat Require Antibiotics?

Alexander Fleming discovered the first antibiotic, penicillin, in 1928. Penicillin was the first natural antibiotic by interfering with bacteria cell walls.

Key takeaways:
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    Not everyone with a sore throat needs to be treated with an antibiotic for Strep throat. In fact, most do not.
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    On the other hand, if it is determined that someone needs to be treated for Strep throat, it is essential that they are treated, and treated appropriately with the right antibiotic at the right dose.
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    Deciding whether to treat someone with an antibiotic for Strep throat is a clinical decision based on many factors and should be careful and deliberate depending on the history of the patient, physical examination, and any other mitigating factors.
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    Avoidance of antibiotic resistance is a key motivation for judicious use of antibiotics.

In his Nobel Prize acceptance speech in 1945, Alexander Fleming said: “Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug, make them resistant.”

Why not treat everyone who has a sore throat with antibiotics?

In the treatment of Strep throat, the healthcare professional faces challenges. Only about one-third of cases of pharyngitis are caused by Streptococcus and really need an antibiotic. Also, some patients get better on their own without the use of antibiotics.

In addition to what was stated by Alexander Fleming, there are issues with underdosing, under or over prescribing antibiotics, the emergence of drug resistance, and allergies to antibiotics.

To complicate matters even more, some patients do not truly have a bacterial infection such as Strep but get better faster with antibiotics because many antibiotics possess anti-inflammatory properties.

That is one the reasons why antibiotic drugs such as azithromycin gained a lot of popularity in treating Strep in children in particular because of the short-term dosing. The reality is that giving the child an anti-inflammatory drug such as Tylenol or ibuprofen often has the same effect.

Some patients may test positive for Strep throat, meaning their throats are filled with Strep bacteria, but they are not sick. These patients are called carriers and usually they do not need to be treated with antibiotics, but often they are anyway.

To make things even more confusing, a Strep carrier patient can test positive for Strep, take antibiotics, but still keep getting sick. This patient may be a Strep carrier who is merely getting viral pharyngitis repeatedly, so they do not need antibiotics after all.

What do antibiotics do?

The purpose of antibiotics is to treat or prevent diseases that are caused by bacteria.

Antibiotics are not effective against viral infections, such as viral pharyngitis.

Antibiotics should only be used to treat infections that are not likely to be cleared up without antibiotics. Antibiotics either stop bacteria from reproducing (bacteriostatic) or destroy them (bactericidal).

Healthcare providers are often stymied in determining whether someone needs an antibiotic or not, especially when treating patients with sore throats. If antibiotics are overused, then the bacteria can become resistant to treatment.

Most antibiotics have a broad range of effectiveness against certain bacteria. Not all antibiotics are that way.

Some have a narrower spectrum and are only effective in certain cases. Therefore, in a patient with Strep throat, even if an antibiotic is prescribed correctly, it must be the correct one.

How useful are antibiotics in the treatment of Strep throat?

Antibiotics help prevent patients with Strep throat from spreading the infection to others. This is important particularly in school-age children, in daycares, or in close working environments.

Generally, patients with Strep throat should stay home from work or school until they no longer have a fever and have taken antibiotics for at least 12 hours. They should also never stop the antibiotic and complete its full course of treatment.

What are the benefits of being treated with an appropriate antibiotic?

Benefits of antibiotics use in a patient who truly has Strep throat include:

  • Decreasing how long someone is sick.
  • Decreasing symptoms or relieving some of them altogether.
  • Preventing the bacteria from spreading to others.
  • Preventing serious complications like rheumatic fever.
  • Preventing spread of the Strep infection to adjacent areas of the pharynx and voicebox which can become life-threatening, if not treated quickly.

It is unlikely that the Strep bacteria can spread throughout someone’s body (sepsis) if not treated, but it can happen. This is particularly true if the patient has some type of underlying disease process or is immunocompromised.

What happens if Strep throat is not treated with an antibiotic but should be?

Complications can include:

  • Abscesses around the tonsils or in the neck. These are usually associated with pockets of white or yellow, foul-smelling pus. Antibiotics may not be sufficient treatment and the patient may need incision and drainage and steroid treatment.
  • Swollen lymph nodes in the neck.
  • Sinus infections. Not all sinus infections require antibiotic treatment, but sinusitis may develop if the Strep throat is not treated adequately.
  • Ear infections.
  • Rheumatic fever (a disease that can affect the heart, joints, brain, and skin).
  • Post streptococcal glomerulonephritis (a kidney disease which is serious enough that may require hospitalization and can be lethal).

What is antibiotic resistance and how do patients get better if typical antibiotics no longer are working?

The overuse of antibiotics was rampant several years ago when treating children for upper respiratory illnesses, sore throats, and ear infections. For many parents, demanding their child get an antibiotic was commonplace.

In fact, many parents would want to skip the doctor visit altogether and just have a prescription called into the local pharmacy for an antibiotic for their sick child. Awareness of this problem and education turned the tide, albeit slowly. It is still an issue in many medical practices.

The overuse of antibiotics has led to serious infections such as intractable lower gastrointestinal illnesses caused by the bacteria Clostridium difficile. The growing emergence of other multidrug resistant organisms followed, including Gram-negative bacteria including extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella species, and carbapenem-resistant Klebsiella pneumoniae and Pseudomonas aeruginosa.

The problems of antibiotic resistance mean that other, more broad-spectrum, or more powerful antibiotics must be used instead of the old mainstays such as penicillin. An example is the need for adding other agents to penicillin like drugs such as amoxicillin-clavulanate (Augmentin).

Antibiotic resistance is a natural phenomenon. Micro-organisms adapt quickly and efficiently. In fact, some micro-organisms make sure they change only enough to make the host (patient) sick but are not lethal. In a way, that effort ensures that they can survive as well.


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