From the Guidelines
For an 11-year-old male who developed a rash from penicillin while being treated for strep throat, the recommended alternative treatment is azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days or clarithromycin 15 mg/kg/day divided twice daily (maximum 250 mg twice daily) for 10 days, as stated in the 2012 update by the Infectious Diseases Society of America 1.
Key Considerations
- The patient should discontinue the penicillin immediately to prevent further allergic reactions.
- Cephalexin is another option at 25-50 mg/kg/day divided twice daily (maximum 500 mg twice daily) for 10 days, but should be used cautiously due to potential cross-reactivity with penicillin (around 10%) 1.
- It's essential to document this allergic reaction in the medical record and inform the parents to report it to future healthcare providers.
- The rash should be monitored - if it worsens, becomes painful, involves mucous membranes, or is accompanied by breathing difficulties, immediate medical attention is needed.
Rationale
- Azithromycin and clarithromycin are effective against Group A Streptococcus while avoiding beta-lactam structures that triggered the allergic reaction.
- Complete treatment is essential to prevent complications like rheumatic fever or post-streptococcal glomerulonephritis, as emphasized in the American Heart Association's scientific statement 1.
- The choice of alternative antibiotic should be based on the patient's medical history, potential allergies, and the severity of the allergic reaction.
Additional Guidance
- The patient's response to the alternative antibiotic should be closely monitored, and adjustments made as necessary to ensure effective treatment and minimize the risk of further complications.
- The importance of completing the full treatment course should be emphasized to the patient and their parents to prevent the development of antibiotic-resistant strains of Group A Streptococcus.
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. NOTE: Penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever. Azithromycin is often effective in the eradication of susceptible strains of Streptococcus pyogenes from the nasopharynx
The treatment for an 11-year-old male who was strep positive 2 days ago but developed a rash from penicillin is azithromycin as an alternative to first-line therapy, since the patient cannot use the first-line therapy (penicillin) due to the rash 2.
From the Research
Treatment Options for Strep Positive Patient with Penicillin Rash
- The patient is an 11-year-old male who was strep positive 2 days ago but developed a rash from penicillin, indicating a need for alternative antibiotic treatment 3.
- Macrolides, such as clarithromycin and azithromycin, are rational alternatives to erythromycin for streptococcal pharyngitis/tonsillitis in penicillin-allergic patients 3.
- A study comparing 10 days of clarithromycin with 5 days of azithromycin found that clarithromycin was more effective in eradicating group A streptococci from the throat 4.
- Another study found that 5 days of clarithromycin or amoxicillin/clavulanate treatment had clinical efficacy comparable to 10 days of penicillin V treatment, but amoxicillin/clavulanate and penicillin V were bacteriologically more effective than clarithromycin 5.
- Azithromycin has been shown to be effective in killing Streptococcus pneumoniae, but its effectiveness may be reduced in areas with high resistance rates 6.
- A systematic review of different antibiotic treatments for group A streptococcal pharyngitis found that cephalosporins, macrolides, and carbacephem may be effective alternatives to penicillin, but the evidence is uncertain and more research is needed 7.
Recommended Treatment
- Based on the available evidence, clarithromycin or azithromycin may be suitable alternatives to penicillin for the treatment of streptococcal pharyngitis/tonsillitis in penicillin-allergic patients 3, 4.
- The choice of antibiotic should be based on the patient's medical history, allergy status, and local resistance patterns 7.
- It is essential to consult with a healthcare professional to determine the best course of treatment for the patient 3, 5, 6, 4, 7.