Streptococcal pharyngitis, commonly called strep throat, is one of the most common bacterial infections we see in school-age children. It is treatable with a short course of antibiotics, but not every sore throat is strep, and we test before we treat. This handout covers how strep typically presents, who gets tested, what treatment looks like, and when a call is warranted.
Key Takeaways
- Strep throat is caused by Group A Streptococcus (GAS). It is most common between ages 5 and 15.
- A sore throat that comes with cough, congestion, hoarseness, or conjunctivitis is almost always viral, not strep.
- Diagnosis requires a throat swab (rapid antigen test, rapid molecular test, or culture). Treatment based on symptoms alone is not recommended.
- First-line treatment in children without a penicillin allergy is amoxicillin once daily for 10 days, dosed by weight.
- Children can return to school at least 12 hours after the first dose of antibiotics, provided they are afebrile (temperature under 100.4°F without fever-reducing medication) and feel well enough to participate.
What Is Strep Throat?
Strep throat is a bacterial infection of the throat and tonsils caused by Streptococcus pyogenes (Group A Streptococcus). It spreads through respiratory droplets (coughing and sneezing) and through direct contact with saliva or nasal secretions, often in schools, sports teams, and households. Incubation is typically 2 to 5 days.
How It Presents
- Sudden sore throat.
- Fever.
- Painful swallowing.
- Red, swollen tonsils, sometimes with white or yellow patches.
- Tender, swollen lymph nodes at the front of the neck.
- Small red spots on the roof of the mouth (palatal petechiae).
- Headache, stomachache, or nausea and vomiting, particularly in younger school-age children.
- Scarlet fever: a fine, sandpaper-textured pink-red rash, often with a red “strawberry” tongue and flushed cheeks. This is caused by the same bacterium and is treated the same way.
Features that point away from strep include prominent cough, runny nose, hoarseness, conjunctivitis, mouth ulcers, and diarrhea. A child with those findings most likely has a viral illness and generally does not need to be tested.
Who Gets Tested
Strep circulates year-round in Florida, not just in the winter, so do not assume a summer sore throat with classic features is not strep. Some local schools and daycares request a physician note for re-entry. ELP can provide one. In general, we swab when sore throat is paired with fever, swollen front-of-neck lymph nodes, or tonsillar exudate, and when cough and runny nose are absent. When the picture clearly points to a virus, swabbing is not helpful. Testing is guided by the clinical picture and by age:
- Children under 3: testing is usually not recommended. Exceptions include a sibling or close contact with confirmed strep, features beyond a simple sore throat (scarlet fever rash, marked exudate), or persistent symptoms in an older toddler with school-age siblings. Classic strep pharyngitis and the complications antibiotic treatment prevents are rare at this age.
- Children 3 and older with sore throat and features suggesting strep (fever, swollen tender cervical nodes, exudative tonsils, absence of cough or congestion): we recommend a throat swab.
- Testing options include a rapid antigen test (results in minutes, a positive result is diagnostic, a negative result in children is often reflexed to culture because sensitivity is not perfect), a rapid molecular test (high sensitivity, results within an hour), and traditional throat culture (gold standard, results in 24 to 48 hours).
Treatment
Finish the full 10-day course even if symptoms improve within a few days. Shortening treatment increases the risk of incomplete eradication and of rheumatic fever.
First-line (no penicillin allergy).
Amoxicillin 50 mg/kg once daily (maximum 1000 mg per day) for 10 days is preferred in pediatrics because of the simplicity of once-daily dosing and good adherence. Alternatively, amoxicillin can be given as 25 mg/kg twice daily.
Penicillin V option.
Penicillin V 250 mg by mouth 2 to 3 times a day for children under 27 kg, or 500 mg 2 to 3 times a day for children 27 kg and over, for 10 days. Less popular than amoxicillin in kids because of dosing frequency and taste.
Penicillin allergy.
For non-anaphylactic penicillin allergy, cephalexin 20 mg/kg per dose by mouth twice daily (maximum 500 mg per dose) for 10 days is preferred. For severe (anaphylactic) penicillin allergy, clindamycin is the more reliable option. Azithromycin is an alternative, though some communities have measurable macrolide resistance. We will choose based on the local picture. Let us know about any antibiotic reactions. If your child carries a penicillin allergy label from a remote childhood reaction (rash on antibiotics as a young child, no other symptoms), ask us about allergy reassessment. The majority of those labels are not true allergies, and clearing them up opens better treatment options.
Supportive care.
Weight-appropriate acetaminophen or ibuprofen for pain and fever. Cool fluids, popsicles, and soft foods help while swallowing is painful. Honey for children 12 months and older can soothe the throat. No honey under 12 months.
Why Treatment Matters
- Shortens symptom duration and time to recovery.
- Reduces contagiousness (children are generally non-contagious after 12 to 24 hours on antibiotics, provided fever has resolved).
- Prevents acute rheumatic fever, a serious complication that can affect the heart.
- Prevents peritonsillar abscess and other local complications.
Post-streptococcal glomerulonephritis is a separate complication that is not prevented by antibiotic treatment of pharyngitis.
Return to School
Children can return to school at least 12 hours after the first dose of antibiotics, as long as they are afebrile (temperature under 100.4°F without fever-reducing medication) and feel well enough to participate. Some schools and daycares require 24 hours on antibiotics or a physician note for re-entry. Check your school’s specific policy. ELP can provide a return-to-school note if needed.
Household Contacts
Routine testing of asymptomatic household contacts is not recommended. Household contacts who develop symptoms (sore throat, fever) should be evaluated. Families with recurrent strep in multiple members, or a history of post-streptococcal complications in a household member, should ask us about carrier testing.
When to Call Us
- A sore throat with high fever, swollen glands, or difficulty swallowing.
- Symptoms that are not improving after 48 to 72 hours of antibiotics, or worsening at any point on treatment.
- Difficulty breathing, drooling, inability to swallow saliva, or muffled (“hot potato”) voice: go to the emergency department.
- A rash, especially sandpaper-textured, along with sore throat.
- Dark or tea-colored urine, significant facial swelling, or decreased urine output during or after a strep infection (possible post-streptococcal kidney complication).
- New joint pain, chest pain, or unusual movements during or after a strep infection (warrants evaluation for rheumatic fever).
- Any medication reaction during or after the antibiotic course: rash that is worsening, hives, swelling of face or lips, difficulty breathing, or persistent vomiting or diarrhea on antibiotics.
Prevention
- Frequent handwashing with soap and water for at least 20 seconds.
- Cover coughs and sneezes with an elbow or a tissue.
- Do not share utensils, water bottles, or toothbrushes during an illness.
- Consider replacing your child’s toothbrush once they are feeling better.
- Disinfect high-contact surfaces during active illness in the household.
Bottom Line
Strep is common, treatable, and usually uncomplicated when diagnosed with a swab and treated with the right antibiotic for the full course. Do not treat a sore throat with antibiotics without a positive test. Most sore throats are viral. Call us for any concerning symptom during or after treatment.
Call ELP at (727) 372-6760 or schedule online. Stay healthy my friends.
Sources
- Infectious Diseases Society of America (IDSA) Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis (most recent revision).
- American Academy of Pediatrics, Red Book: Group A Streptococcal Infections (current edition).
- AAP HealthyChildren.org: strep throat and sore throat articles.
- Seattle Children’s / Schmitt Pediatric Guidelines: Sore Throat.
