A woman drinking tea and holding her throat to indicate she is suffering from strep throat

“You mean you’re not going to prescribe an antibiotic?”

The disappointed patient was a 50-year-old stockbroker who came to see me with a four-day history of sore throat, coughing, postnasal drip, and low-grade fever. He said that his previous physician had always given him a Z-Pak (a five-day course of the antibiotic azithromycin) for similar symptoms and that he always got better.

I explained that it was more likely that he had a viral infection, for which an antibiotic would be useless. And I outlined some over-the-counter measures that might help. But he left the office in a huff, and I never saw him again.

Sussing Out Strep

Today, there is no need to give antibiotics “just in case” it’s strep. The organism can be reliably detected with a simple throat swab, with results available within 24 hours, or in minutes with the less reliable rapid strep test. (Kids who get a negative result on a rapid strep test should get a follow-up throat culture to confirm their diagnosis. Adults don't need additional testing, according to UpToDate, which provides evidence-based treatment information to healthcare providers.)

More on Antibiotics Overuse

But strep throat can almost always be distinguished from a viral sore throat on clinical grounds alone.

The patient is usually younger than 50, and the sore throat comes on like gangbusters within hours or overnight, making swallowing so difficult that drooling can occur. The breath has a foul odor, and even speech is affected. A fever over 101° F, accompanied by chilly sensations, is common, and you can easily feel tender swollen lymph nodes under the jaw. 
Inspection of the throat shows yellowish pus overlying the tonsils. Because group A strep evidently lacks the ingenuity to have developed resistance, penicillin is still the mainstay of treatment unless the patient is allergic to it.

A viral sore throat develops over the course of a few days and is invariably accompanied by a runny nose, postnasal drip, 
a cough with clear or greenish sputum, and a low-grade fever or no fever at all. No medicine will cure it. The only treatment is “tincture of time”—waiting out the one to two weeks it can take for symptoms to abate on their own.

The flu (also a viral illness) has symptoms similar to a viral sore throat except for more intense muscle aches and perhaps a higher fever. It's treatable with the antiviral drug oseltamivir (Tamiflu and generic) if given early enough in the course of the illness. See our advice on how to identify and treat colds and the flu.

Antibiotics for a Sore Throat?

The age of antibiotics began in the 1930s with the introduction of sulfa drugs, followed by penicillin in 1941. In the last half-century, antibiotics have saved the lives of countless millions infected with deadly bacteria.

The war against viruses, with a few notable exceptions, has not been as successful. Nonetheless, physicians began writing antibiotic prescriptions for many viral infections “just in case” bacteria might also be involved. Patients came to expect and even demand such treatment, like my stockbroker ex-patient. That’s not good medicine.

Unnecessary antibiotics not only expose patients to harmful side effects, such as debilitating diarrhea, but also lead directly to the emergence of resistant strains of bacteria that then go on to infect others.

The Centers for Disease Control and Prevention estimates that 20 to 50 percent of all antibiotics prescribed in hospitals is either unnecessary or inappropriate. In doctor’s offices, the percentage may be even higher.

Nowhere is this more evident than in the treatment of sore throats, which is one of the most common reasons adults and children visit their doctor’s office. Even though it has been shown that a vast majority of sore throats are due to a variety of respiratory viruses such as adenovirus, respiratory syncytial virus, and rhinovirus, they are still frequently treated with antibiotics.

Physicians probably overuse antibiotics for viral sore throats in part to appease miserable patients desperate for a quick cure. But the practice also dates back to a time when untreated sore throats were occasionally followed by rheumatic fever or acute kidney disease.

Those complications developed from infections caused by the group A beta-hemolytic streptococcus—the infamous strep throat—that account for only 5 to 15 percent of all sore throats in adults (and 15 to 30 percent of all sore throats in children). The only other sore throat that can mimic strep throat (but with a negative throat culture) is that which occurs with infectious mononucleosis. 

Just because it's not strep, however, doesn't mean there's nothing you can do to feel better. You can manage ordinary sore-throat symptoms with acetaminophen (Tylenol and generic), nasal sprays or drops, throat lozenges, and gargling with warm salted water. Of course, there’s always good old chicken soup, which, in my opinion, would have helped that stockbroker more than a whole carload of Z-Paks.