What doctors wish patients knew about strep throat

We all know that uncomfortable feeling of a sore throat. But there can be multiple reasons why someone’s throat hurts, is scratchy or feels unusual. It could be the common cold, flu, COVID-19 or seasonal allergies. But it could also be strep throat, which can occur at any point, but typically appears in late autumn, winter or early spring. Knowing what to expect is key to determining if it is strep throat or a viral infection.

Strep throat, or pharyngitis, causes about 5.2 million outpatient visits each year in the U.S. It is also the reason for 2.8 million antibiotic prescriptions annually among non-Medicare age patients, according to the Centers for Disease Control and Prevention. But strep throat is most common among children 5–15 years old. Meanwhile, strep throat is rare in children younger than 3 years old. Group A strep pharyngitis is most common in winter and spring in the U.S.

The AMA’s What Doctors Wish Patients Knew™ series provides physicians with a platform to share what they want patients to understand about today’s health care headlines.

In this installment, two physicians took time to discuss what patients need to know about strep throat. They are:

• Whitney Hardy, MD, a family physician and an associate medical director for primary care at Ochsner Health in Gretna, Louisiana.
• Nikita Patel, MD, a pediatrician at Ochsner Health in Marrero, Louisiana.

Ochsner Health is a member of the AMA Health System Program, which provides enterprise solutions to equip leadership, physicians and care teams with resources to help drive the future of medicine.

“Strep throat is a bacterial infection of the throat and tonsils,” said Dr. Hardy. “What really differentiates strep throat from other causes of sore throat—which are largely viral in nature—is the fact that the strep bacteria is involved.”

“There's a very specific bacteria called group A Streptococcus and that specific bacterium can really cause a constellation of different symptoms,” said Dr. Patel. “It can cause the typical strep throat or sore throat type of symptoms that we're familiar with.”

Strep throat “can actually present in a lot of different ways, depending on your age group as well,” she added. “If you’re over the age of 3 and you’ve been exposed to strep throat or have a current infection with strep throat, the most common symptoms that we’re familiar with usually include fever, having that sore throat type of feeling and fatigue.”

“You can also have headaches, and belly-aches or abdominal pain with it as well,” Dr. Patel said. “But at the back of your throat where your tonsils are, you can notice redness. Sometimes you can have white patches of exudates, which is kind of like pus or streaks of that as well.”

“In some severe cases you’ll get swelling in the glands of your neck,” Dr. Hardy said.

“Whenever we talk about symptoms, there are ways you would be able to differentiate whether something is strep versus if it’s a viral pharyngitis or a viral sore throat,” Dr. Hardy said. “One of the criteria that we use is whether or not there is a cough.

“Usually with strep you will not have a cough—you’re not going to cough up any phlegm,” she added. “You’ll just have the fever and the sore throat and the other symptoms. But if you are having a cough, then that’s a good sign that it’s likely a viral illness because strep doesn’t affect the lower respiratory tract.”

In children younger than 3 years old, strep throat is rare and “it doesn’t always come in that particular sore throat type of feeling,” Dr. Patel said. “It can sometimes come in with lots of copious congestion, fatigue, those types of things in kids who are less than 3 years old.”

“That’s when our history-taking really is key,” she said. “So, if we’re finding out the younger brother or older brother went to school and has these same symptoms, we have to think if it is a possibility that the older brother has strep and should we test the younger babies for it.”

“One of the problems is the incubation period for strep throat. In that two-to-five-day window when you may not be quite symptomatic and febrile yet, you could still pass it on because strep throat is highly contagious,” Dr. Hardy said, noting “it is passed on mainly through respiratory droplets.”

“What that means is that if someone … is not very good at washing their hands very well or covering their mouth whenever they are coughing or sneezing, anything like that releases some of the particles that might be at the back of our throat,” Dr. Patel said. “In doing that, they can spread droplets that way too, so it can live temporarily on surfaces.

“There are two common tests that are available. The most common ones are your rapid antigen tests and those are usually swabs,” Dr. Patel said, noting “they might be two-pronged, so they might look like two Q-tips at the same time in which case we swab the back of the throat or the tonsils to collect a sample.”

For the rapid strep test, “we would give to our patients in the office. It’s something that we can have the results for in about 15 minutes,” Dr. Hardy said.

“The other common test that we'll see is a rapid molecular test, which is becoming a little bit more popular,” she said. “However, it is a little bit more costly and luckily with that one it's just a single Q-tip sample that we have to do at the back of the throat or the tonsils.

“And because it's more accurate, we don't typically have to do a throat culture, so we don't have to send off for an additional test,” Dr. Patel added. The reason the rapid test is “two-pronged is that the first test is done and sometimes it might be a false negative, so we send off a throat culture where we see if the bacteria grow in that.” 

What doctors wish patients knew

Subscribe for the answers to the latest questions patients are bringing to the exam room.

Subscribe Now

How long strep throat lasts is “one of those things that depends on the individual,” Dr. Hardy said, noting that “most people are better with a course of antibiotics in about five to seven days.

“In some cases, it can take a little longer to recover, especially if it was a severe case,” she added. For example, “those who are older or have immunocompromising conditions may take a little bit longer to recover from strep throat.”

“As far as not being contagious, that’s typically within 24 to 48 hours on antibiotics,” Dr. Hardy said, noting that when considering returning to work, school or other daily activities, “a good sign is your fever has resolved.”

“Also, sometimes people will lose their voice, or they may just feel weak and have fatigue, so you would want those symptoms to be better as well before you go back to your daily life,” she said.

“Because strep throat is a bacterial infection, it is very unlikely that it will resolve without a course of antibiotics,” Dr. Hardy said, noting that “the most common antibiotics that we use are amoxicillin and penicillin.”

Strep throat will typically be treated with antibiotics “for about 10 days to make sure the bacteria is gone,” she explained. But “once we start the antibiotics and you’ve been on those for 24 to 48 hours, the ability to spread it goes way down.”

“Sometimes even after a single dose you’ll start seeing that you or your child feel better,” she said. “However, we highly recommend that kids and families finish the course of antibiotics as prescribed because we want to make sure that infection is cleared completely.”

“Unfortunately, yes, you can get strep throat again,” Dr. Hardy said. “What causes that is that sometimes the strep bacteria can remain in the tonsils even after the infection is treated.

“That person would become a carrier of strep. They might not have high enough amounts of strep to be sick, but that means if their immune system is put under stress, it could reactivate,” she added.

“One of the more common reasons that families will pursue talking to a specialist such as an ear, nose and throat doctor is current episodes of tonsilitis or exudative tonsillitis or recurrent episodes of strep throat,” Dr. Patel said. “So, if we’re having a significant number of recurrent illnesses, then that might be something that needs to be discussed.”

If you have had your tonsils removed, “the risk is greatly reduced because that bacteria will typically infect the tonsils,” Dr. Hardy said. But you can still get strep.

“A very common misconception is that once you have your tonsils removed that you can’t get strep throat,” Dr. Patel said. “However, strep throat is just one form of having the strep A bacteria present, so you can still get a strep throat infection.

“You can still get it in different parts of your throat,” she added, noting “you can also have it present as a skin rash or other infections as well.”

Strep throat is “a sore throat like no other,” said Dr. Hardy, but there are some things patients can do at home to relieve their symptoms.

For example, “avoiding very hot or spicy foods,” she said. Also, “you want to have a soft, bland diet, avoiding smoke or smoky environments.”

“You can also do warm saltwater gargles and you can drink hot tea with honey,” Dr. Hardy said. “We usually recommend people take either Tylenol or ibuprofen to help break their fever and that can also manage the pain.”

To protect yourself from strep throat or from spreading it to others, “washing your hands is one of the most basic things you can do,” Dr. Hardy said. It is also important to make “sure that you cover any coughs or sneezes.”

Additionally, “make sure you avoid sharing drinks and utensils, and then just stay away from other people as much as possible when you’re sick,” she said.

“You want to make sure that all of those areas that are being touched pretty often are cleaned and wiped down,” Dr. Hardy said. “You should use, for example, Lysol wipes or soap and water to wipe those areas down.”

When cleaning, everyone should be “thinking about light switches, countertops and appliances,” she said.

“Once we start a treatment for strep throat, then I’ll actually suggest sometimes replacing toothbrushes, making sure that stuffed animals—or anything that they specifically sleep with at night—gets washed,” Dr. Patel said.

“The biggest thing when it comes to a strep throat infection is that we want to make sure that kids are able to stay hydrated and not get to the point where they need to be seen in the hospital,” Dr. Patel said. “If your child is having difficulty swallowing and maintaining adequate hydration or they’re complaining that it hurts a lot to drink fluids, that might be a sign that their throat is in a significant amount of pain that we want to make sure to get checked out.”

“If your child is really having a hard time keeping up with fluids, then colder items can help kind of numb up the back of their throat a little bit better, so kids are more likely to tolerate it,” she said. “So, I’ll tell families you can give kids Pedialyte popsicles to help give them the appropriate electrolytes and fluid hydration while also feeling cold.”

“It’s important for families to realize the complications to watch out for when it comes to strep throat or improperly treated strep throat,” Dr. Patel said.

These include complications such as “abscesses or more serious infection in your tonsils or close to your tonsils,” she said. “The bacteria can end up making a pocket—kind of like a boil—behind the tonsils and that can be something that’s excruciatingly painful and will not improve on its own just with antibiotics by mouth.”

“You can also have post streptococcal glomerular nephritis. That is a rare complication that happens due to the way the immune system may respond to certain strains of strep bacteria, leading to improper kidney function,” she said. “But this does not occur directly from a toxin from a strep bacterium.”

Rheumatic fever is also a complication to watch out for. Rheumatic fever is a condition that can affect the heart, joints, brain and skin if strep throat is not treated properly. It can take about one to five weeks after strep throat infection for rheumatic fever to develop.