Strep throat is best diagnosed with a rapid antigen test or throat culture. Empirical treatment without testing leads to unnecessary antibiotics; not testing when criteria are met (sudden onset sore throat, fever, no cough, tender anterior cervical lymph nodes, age 3-15) can miss true strep. Treatment is penicillin or amoxicillin for 10 days, or a single-dose cephalosporin alternative. Fishtown Medicine handles strep evaluation and treatment same day for members, often by video plus a pharmacy-administered rapid test if appropriate.
Strep throat is one of those acute complaints where the right answer is simple: test for it, treat if positive, move on. The complications come from getting test access in a reasonable time frame and from inappropriate prescribing in cases where strep is not present.
When strep is more or less likely
Centor criteria (or modified Centor) help estimate probability:
- Tonsillar exudate (+1)
- Tender anterior cervical lymph nodes (+1)
- Fever (+1)
- Absence of cough (+1)
- Age 3-15 (+1) or 15-44 (0) or 45+ (-1)
Score 0-1: strep unlikely; no testing or treatment usually needed. Score 2-3: rapid antigen test; treat if positive. Score 4+: high probability; rapid test and treat if positive; some guidelines support empirical treatment.
In adults presenting with sore throat alone, sudden onset without cough, fever, tender lymph nodes, and tonsillar exudate makes strep more likely.
Testing options
- Rapid antigen test (RADT): Fast result, reasonable sensitivity (about 80-90%) and high specificity. Negative tests in patients with high pre-test probability should usually be followed by culture.
- Throat culture: Gold standard but takes 1-2 days. Used to confirm negative rapid tests in patients with high probability.
- PCR: Higher sensitivity, available at most labs, often results within hours.
Treatment
Standard treatment is penicillin V or amoxicillin for 10 days. Amoxicillin is generally preferred for tolerability. For penicillin allergy, cephalosporins (cefadroxil, cefuroxime) for 10 days or azithromycin for 5 days are alternatives. Recently approved shorter-course cephalosporin regimens (5-day cefdinir) are also reasonable.
Most patients improve within 24-48 hours. Symptoms persisting beyond 72 hours warrant reassessment.
Why treat strep at all
The main reasons:
- Symptom reduction.
- Prevention of acute rheumatic fever (rare in adults; more relevant in children in resource-limited settings).
- Prevention of peritonsillar abscess and other suppurative complications.
- Reduced transmission.
The rationale for treating in adults is weaker than in children, but most guidelines still recommend treating documented strep.
Fishtown Medicine
A 90-minute conversation with Dr. Ash. A written plan you can actually follow.
How strep evaluation works at Fishtown Medicine
For members, we triage by message and decide whether a video visit is sufficient or whether you need to come in for a rapid test. Some patients can do a rapid test at a pharmacy and message us the result; others need a throat culture or in-person exam. Most cases resolve in a same-day encounter.
For non-members, we offer pay-what-you-can urgent care evaluation for routine acute issues.
What it costs
For members, strep visits are included in the membership. Antibiotics (penicillin, amoxicillin) are inexpensive at most Philadelphia pharmacies.
For non-members, the pay-what-you-can urgent care line is the appropriate option.
Key Takeaways
- Strep throat needs a test (rapid antigen or culture) to diagnose accurately.
- Treatment is penicillin or amoxicillin for 10 days, with cephalosporin alternatives.
- Most patients improve within 24-48 hours.
- Fishtown Medicine handles strep same-day for members; pay-what-you-can urgent care available for non-members.
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