A 28-year-old woman from rural Maharashtra presents with a 3-day history of severe sore throat, fever (39.2°C), and difficulty swallowing. On examination, she has bilateral exudative pharyngitis with enlarged cervical lymph nodes. A rapid antigen detection test (RADT) is positive for Group A Streptococcus. She has no penicillin allergy. Which of the following is the most appropriate immediate management?

Explanation

## Acute Group A Streptococcal Pharyngitis: First-Line Management **Key Point:** Penicillin V (oral penicillin) is the gold-standard first-line antibiotic for Group A Streptococcus (GAS) pharyngitis in non-severe cases, regardless of symptom severity or RADT positivity. ### Rationale for Penicillin V 1. **Excellent efficacy**: GAS remains universally susceptible to penicillin; no resistance has ever been documented. 2. **Optimal dosing**: 250 mg orally QID for 10 days achieves adequate pharyngeal and tonsillar concentrations. 3. **Prevention of sequelae**: Antibiotic initiation within 9 days of symptom onset prevents acute rheumatic fever (ARF) and post-streptococcal glomerulonephritis (PSGN). 4. **Cost-effectiveness**: Penicillin is inexpensive and widely available in India. **High-Yield:** The 10-day course duration is non-negotiable—it ensures eradication of GAS from the pharynx and prevention of nonsuppurative sequelae. ### Why Other Options Are Suboptimal | Agent | Why Not First-Line | |-------|-------------------| | **Azithromycin** | Macrolide resistance in GAS is rising (10–30% in some regions). Reserve for penicillin allergy. | | **Cephalexin** | First-generation cephalosporin; acceptable alternative if penicillin allergy (non-anaphylaxis), but NOT preferred when penicillin is available. | | **Supportive care alone** | Delays symptom resolution and increases risk of ARF/PSGN. Antibiotics are indicated once GAS is confirmed. | **Clinical Pearl:** RADT positivity in a patient with classic pharyngitis (exudate, fever, lymphadenopathy) is sufficient to initiate antibiotics; throat culture confirmation is NOT required before starting treatment. **Warning:** Do not confuse penicillin V (oral) with penicillin G (parenteral). For uncomplicated pharyngitis, oral penicillin V is standard; IM penicillin G is reserved for severe invasive disease or non-compliance risk.