Strep Throat: What Published Guidance Supports

Key takeaways

• Most common in: children aged 5 to 15
• Typical symptoms: sore throat that starts quickly, pain swallowing, fever, red swollen tonsils, swollen neck glands
• Most useful single change: See your doctor or urgent care for a strep test if you have a sore throat with fever and no cold symptoms.
• Commonest mistake: Using leftover antibiotics or someone else's prescription.
• See a doctor if any of the signs under "When to speak to a doctor" below apply to you.

What it is

A throat and tonsil infection caused by group A Streptococcus bacteria. It sits within Infectious Diseases. What follows are the published numbers, not the ones that get passed around.

The numbers, in one place

What helps

These are the changes with the clearest evidence behind them. Start wherever it is easiest to start.

• See your doctor or urgent care for a strep test if you have a sore throat with fever and no cold symptoms
• Take every dose of the antibiotic for as long as prescribed, even after you feel better
• Use acetaminophen (Tylenol) or ibuprofen for pain, and drink cool fluids or eat soft foods
• Replace your toothbrush and do not share cups or utensils

What to avoid

The common mistakes, including the ones that sound sensible.

• Using leftover antibiotics or someone else's prescription
• Stopping antibiotics early because the throat feels better
• Giving aspirin to children or teens

In depth

Group A Streptococcus bacteria attach to the lining of the throat and tonsils and release substances that trigger strong inflammation. That inflammation causes the sudden, painful sore throat, swollen tonsils and fever that set strep apart from most colds. The bacteria spread through droplets from coughs and sneezes and by sharing cups, utensils or food, and symptoms usually start two to five days after exposure.

Most sore throats are caused by viruses and get better on their own, so antibiotics do not help them. Strep throat is the main exception. Treating it with antibiotics shortens the illness, cuts the time you can spread it to others, and prevents complications such as an abscess near the tonsils and rheumatic fever, an immune reaction that can permanently damage the heart valves.

Some people with strep throat develop scarlet fever, a red, sandpaper-like rash that usually starts on the neck and chest, sometimes with a bright red tongue. It is caused by a toxin some strains make and is treated the same way. Some people carry group A strep in their throat without being ill; these carriers rarely spread it and usually do not need treatment.

Signs and symptoms

• A sore throat that comes on quickly rather than building over days
• Pain when swallowing
• Fever
• Red, swollen tonsils, sometimes with white patches or streaks of pus
• Tiny red spots on the roof of the mouth
• Tender, swollen glands in the front of the neck
• Headache, stomach ache, nausea or vomiting, especially in children

Causes and risk factors

• Close contact with someone who has strep throat
• Sharing cups, utensils, food or toothbrushes
• Crowded settings such as schools, child care centers and military barracks
• Being a school-age child, or an adult who lives or works with children
• Late fall through early spring, when it is most common
• Not covering coughs or washing hands regularly

How it is checked

You cannot tell strep from a viral sore throat by looking alone, so testing is the key step. A rapid strep test uses a quick throat swab and gives a result in minutes at a clinic, urgent care or some pharmacies. Because rapid tests can miss some infections, a negative result in a child or teen is usually followed by a throat culture, which takes a day or two. Adults usually do not need the culture.

Doctors generally do not test people whose symptoms point clearly to a virus, such as cough, runny nose, hoarseness or pink eye, or children under 3, in whom strep throat is uncommon. Testing people who have no symptoms after a family member is diagnosed is generally not recommended either, unless your doctor advises it for a specific reason.

Treatment and support options

Antibiotics

Penicillin or amoxicillin is usually the first choice because group A strep has not become resistant to them. People with a penicillin allergy can be treated with other antibiotics. Some are taken for about 10 days, so set reminders and finish the whole course even if your throat feels better after a day or two. Stopping early raises the risk of complications.

Easing the pain

Acetaminophen (Tylenol) or ibuprofen can ease throat pain and fever. Cold drinks, ice pops, warm tea with honey for anyone over 1 year, and soft foods such as yogurt or soup make swallowing easier. Throat lozenges can help older children and adults, but they are a choking risk for young children. Do not give aspirin to children or teens.

Allergy evaluation

Many people who were told as children that they were allergic to penicillin are not allergic now. If you have a penicillin allergy label, ask your doctor whether allergy testing makes sense. Removing an incorrect label opens up the most effective, narrow antibiotics for future infections.

Frequent infections

Children who get strep throat many times a year may be referred to an ear, nose and throat (ENT) specialist to discuss removing the tonsils. The decision depends on how often infections happen, how well they were documented with tests, and how much school and daily life are affected. Many children have fewer infections as they get older.

Prevention

• Wash hands often with soap and water, especially before eating
• Cover coughs and sneezes with a tissue or your elbow
• Do not share cups, utensils, food or toothbrushes
• Keep a sick child home until the fever is gone and at least 12 hours of antibiotics have been taken
• Wash dishes and utensils in hot soapy water or a dishwasher

Day to day

Most people feel noticeably better within a day or two of starting antibiotics. Offer plenty of fluids, even if swallowing hurts, and watch for signs of dehydration in children. Rest is fine, but there is no need to stay in bed once the fever is gone.

If one person in the household has strep throat, watch others for symptoms over the following week and get them tested if a sore throat and fever develop. Pay attention to the person who was sick for a few weeks afterward too: new joint pain, a rash, dark urine or swelling of the face are uncommon but worth reporting to your doctor.

For specific groups

Children

Strep throat is most common in school-age children. Younger children may complain of a stomach ache rather than a sore throat, or simply refuse food. Ask your child's school or child care center about their return policy, which usually follows the 12-hour antibiotic rule.

Adults

Adults get strep throat less often than children, but parents of school-age children and people who work with children are at higher risk. Because most adult sore throats are viral, testing is the best way to know whether antibiotics will help.

Pregnancy

Strep throat can be treated during pregnancy with antibiotics considered safe, such as penicillin or amoxicillin. Let the clinician know you are pregnant. Group A strep throat is different from the group B strep test done near the end of pregnancy.

Questions to ask your doctor

• Should I or my child have a strep test?
• Which antibiotic are you prescribing, and for how long?
• When can my child go back to school or child care?
• What should I do if I do not feel better after 48 hours of antibiotics?
• Should I be tested for a penicillin allergy?
• Would my child benefit from seeing an ENT specialist?

More questions, answered

Can strep throat go away without antibiotics?

The symptoms often fade on their own, but untreated strep can be passed to others for weeks and raises the risk of complications such as a tonsil abscess and rheumatic fever. That is why guidelines recommend antibiotics when a test confirms strep.

How long am I contagious?

Once you have taken antibiotics for at least 12 hours and the fever is gone, you are much less likely to spread strep. Without treatment, you can spread it for two to three weeks. Until then, avoid sharing drinks or utensils and wash your hands often.

Can I get strep throat again?

Yes. There are many types of group A strep, and having one does not protect you from the others. Repeated infections are common in school-age children, especially during the cold months.

What is rheumatic fever?

It is an uncommon immune reaction that can follow untreated strep throat, usually a few weeks later. It can cause joint pain and swelling, rash, jerky movements and inflammation of the heart, sometimes leaving permanent valve damage. Prompt antibiotic treatment of strep throat prevents it.

Should I replace my toothbrush?

Some doctors suggest replacing your toothbrush after starting antibiotics as a simple precaution, though the evidence is limited. Store toothbrushes so they do not touch each other, and never share them.

Can adults get scarlet fever?

Yes, though it is far more common in children. Adults with a sore throat and a sandpaper-like rash should see a doctor for testing. It is treated with the same antibiotics as strep throat.

Related topics

• Common Childhood Infections: What the Evidence Actually Says (Children's Health)
• The Evidence on Mouth Cancer Awareness, Without the Hype (Oral Health)
• Colds and Flu: What Published Guidance Supports (Immunity)
• Antibiotic Stewardship: Sorting the Evidence From the Noise (Medicines Safety)

Where to go next

• Answers to the Common Questions on Strep Throat
• Strep Throat: The Quick Reference
• Strep Throat — the reference entry
• Infectious Diseases: The Complete Guide
• Hepatitis A: Sorting the Evidence From the Noise
• The Evidence on Tuberculosis Basics, Without the Hype

When to speak to a doctor

See your doctor if a sore throat lasts more than a few days, comes with a rash, or you do not improve after 48 hours of antibiotics. Call 911 for trouble breathing, being unable to swallow saliva or open the mouth fully, drooling, or a muffled voice with severe throat pain.

Where this comes from

• CDC — About Strep Throat
• MedlinePlus — Strep Throat

How this page was put together

Every figure, recommendation and warning above is taken from the guidance named in Where this comes from. Nothing on this page is inferred, summarized or generalized beyond what those bodies publish: where they give a number, it is their number, and where they are silent, so are we. Pages are rebuilt whenever the underlying record changes. Sign-off by a named clinician, where it has happened, is shown at the top of the page along with the date.

Medical disclaimer

This article is general information, not medical advice. It cannot account for your own history, medication or circumstances. Always speak to your doctor, pharmacist or another qualified health professional before making changes that affect your treatment, and never delay seeking medical advice because of something you have read here. In an emergency, call 911.