From the Guidelines
Management of streptococcal infections primarily involves antibiotic therapy, with penicillin being the first-line treatment, as recommended by the Infectious Diseases Society of America 1. For Group A Streptococcus (GAS) pharyngitis,
- oral penicillin V (250-500 mg twice daily for 10 days)
- or amoxicillin (50 mg/kg once daily, maximum 1000 mg, for 10 days) is recommended 1. For penicillin-allergic patients, alternatives include
- cephalexin (if no anaphylaxis history),
- clindamycin (300 mg three times daily for 10 days),
- azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days),
- or clarithromycin 1. Intramuscular benzathine penicillin G (600,000 units for <27 kg; 1.2 million units for ≥27 kg) is an option for patients with compliance concerns 1. Complete the full antibiotic course even if symptoms resolve quickly to prevent complications like rheumatic fever. Symptomatic relief can include
- acetaminophen or ibuprofen for pain and fever,
- salt water gargles, and
- adequate hydration. For severe invasive streptococcal infections, hospitalization with intravenous antibiotics and possibly surgical debridement may be necessary. Antibiotic treatment helps eliminate the bacteria, reduces symptom duration, prevents transmission, and reduces the risk of complications such as peritonsillar abscess, rheumatic fever, and post-streptococcal glomerulonephritis.
From the FDA Drug Label
In streptococcal infections, therapy must be sufficient to eliminate the organism (10-day minimum); otherwise the sequelae of streptococcal disease may occur. Cultures should be taken following completion of treatment to determine whether streptococci have been eradicated.
The management of strep infections with penicillin V (PO) requires a minimum of 10 days of therapy to eliminate the organism and prevent sequelae of streptococcal disease.
- Key points:
- Therapy should be sufficient to eliminate the organism
- Cultures should be taken after completion of treatment to confirm eradication
- Treatment should be taken exactly as directed to ensure effectiveness and prevent resistance 2
From the Research
Diagnosis of Strep Pharyngitis
- The diagnosis of strep pharyngitis can be made using a combination of clinical evaluation and diagnostic tests, including throat culture and rapid antigen detection testing 3, 4, 5, 6, 7
- Clinical scoring systems, such as the modified Centor score, can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 3, 5, 6
- The presence of symptoms such as fever, tonsillar exudate, cervical lymphadenitis, and patient ages of 3 to 15 years increase clinical suspicion of strep pharyngitis 5, 6
Treatment of Strep Pharyngitis
- Penicillin and amoxicillin are first-line antibiotics for the treatment of strep pharyngitis, with a recommended course of 10 days 3, 4, 5, 6
- First-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 3, 5, 6
- Macrolides, such as azithromycin and clarithromycin, may be used as alternative treatments, but there is significant resistance to these antibiotics in some parts of the United States 5
- Corticosteroids are not recommended for symptomatic treatment of strep pharyngitis, as they provide only a small reduction in the duration of symptoms 5, 6
Management of Strep Pharyngitis
- The management of strep pharyngitis aims to provide symptom relief, shorten the duration of illness, prevent nonsuppurative and suppurative complications, and decrease the risk of contagion, while minimizing the unnecessary use of antibiotics 4, 7
- Tonsillectomy is rarely recommended as a preventive measure for strep pharyngitis, and is typically considered only for patients with recurrent episodes of strep pharyngitis 3, 5
- Nonsteroidal anti-inflammatory drugs and medicated throat lozenges may be used to treat fever and pain associated with strep pharyngitis 6