What is the treatment for streptococcal (strep) pharyngitis?

From the Guidelines

The primary treatment for strep pharyngitis is antibiotics, specifically penicillin or amoxicillin, for a duration of 10 days to eradicate the organism from the pharynx. For adults and children, the recommended regimen is penicillin V 500 mg orally twice daily for 10 days, or amoxicillin 500 mg orally twice daily for 10 days 1. For patients with penicillin allergy, alternatives include a first-generation cephalosporin (for those not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days 1.

Key Considerations

• The choice of antibiotic should be based on the patient's allergy history and the severity of the allergy.
• It's crucial to complete the full course of antibiotics even if symptoms improve quickly to prevent complications like rheumatic fever and peritonsillar abscess.
• Symptomatic relief can be achieved with acetaminophen or ibuprofen for pain and fever, warm salt water gargles, and adequate hydration.
• Patients should stay home from work or school until they've been on antibiotics for at least 24 hours and are fever-free.

Treatment Options

• Penicillin or amoxicillin for 10 days for non-allergic patients 1.
• First-generation cephalosporin, clindamycin, clarithromycin, or azithromycin for patients with penicillin allergy 1.

Prevention of Complications

• Treatment helps prevent complications like rheumatic fever and peritonsillar abscess, reduces symptom duration, and prevents transmission to others 1.
• Secondary prevention of rheumatic fever is crucial for patients who have had a previous attack, and penicillin is the agent of choice for prophylaxis 1.

From the FDA Drug Label

Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates Approximately 1% of azithromycin-susceptible S pyogenes isolates were resistant to azithromycin following therapy.

Treatment for strep pharyngitis: Azithromycin is effective in the treatment of pharyngitis/tonsillitis caused by Streptococcus pyogenes, with a clinical success rate of 98% at Day 14 and 94% at Day 30, as compared to penicillin. However, penicillin is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever. Azithromycin may be used as an alternative to first-line therapy in individuals who cannot use first-line therapy.

• Key points:
  • Azithromycin is effective against Streptococcus pyogenes
  • Penicillin is the first-line therapy
  • Azithromycin may be used as an alternative in certain cases
  • Susceptibility tests should be performed to ensure the bacteria is susceptible to azithromycin 2 2

From the Research

Treatment Options for Strep Pharyngitis

• Oral penicillins are considered first-line agents for the treatment of culture-confirmed group A beta-haemolytic streptococcal tonsillopharyngitis 3.
• Cephalosporins are useful, especially for the treatment of recurrent streptococcal tonsillopharyngitis 3.
• Macrolides, such as erythromycin, can be used as an alternative to penicillins, especially in penicillin-allergic patients, but have higher failure rates and increased resistance 3.
• Azithromycin has been shown to have similar clinical efficacy to penicillin V, but with lower bacteriologic eradication rates 4.

Comparison of Antibiotic Treatments

• Cephalosporins versus penicillin: low-certainty evidence suggests that cephalosporins may have a lower rate of clinical failure, but the difference in symptom resolution is uncertain 5, 6, 7.
• Macrolides versus penicillin: low-certainty evidence suggests that there may be no difference in symptom resolution, but macrolides may have a higher rate of adverse events in children 6, 7.
• Azithromycin versus amoxicillin: very low-certainty evidence suggests that azithromycin may have similar symptom resolution rates, but with more adverse events 6, 7.
• Carbacephem versus penicillin: low-certainty evidence suggests that carbacephem may provide better symptom resolution post-treatment in adults and children 6, 7.

Duration of Antibiotic Treatment

• Short-course antibiotic treatment (≤5 days) may be as effective as long-course antibiotic treatment (≥7 days) for early clinical cure and bacteriologic eradication, but the evidence is uncertain 5.
• Long-course penicillin V should remain as the first-line antibiotic for the management of patients with streptococcal pharyngitis, due to the limited benefits of using other antibiotics and the risk of antimicrobial resistance 5.