What are alternative treatments to Penicillin (Penicillin) for Streptococcal infections in patients with a Penicillin allergy?

From the Guidelines

For patients with penicillin allergies who need treatment for streptococcal infections, azithromycin (12 mg/kg once daily, max 500 mg, for 5 days) is a recommended alternative, as stated in the 2012 update by the Infectious Diseases Society of America 1. This recommendation is based on the most recent and highest quality study available, which provides strong, moderate evidence for the use of azithromycin as an alternative to penicillin in patients with penicillin allergies. Some key points to consider when choosing an alternative to penicillin for streptococcal infections include:

• The severity of the infection
• Local resistance patterns
• The nature of the patient's penicillin allergy
• The specific infection site Other alternatives, such as clindamycin (7 mg/kg/dose, three times daily, max 300 mg/dose, for 10 days) or clarithromycin (7.5 mg/kg/dose, twice daily, max 250 mg/dose, for 10 days), may also be considered, as recommended by the Infectious Diseases Society of America 1. It is essential to note that cephalosporins, such as cefuroxime, should be avoided in patients with immediate-type hypersensitivity to penicillin, due to the risk of cross-reactivity 1. In cases where beta-lactams are preferred, consultation with an allergist for penicillin allergy testing may be warranted, as many patients labeled as penicillin-allergic can actually tolerate these medications 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. 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 Its use should be reserved for penicillin-allergic patients or other patients for whom, in the judgment of the physician, a penicillin is inappropriate. Streptococci: Serious respiratory tract infections; serious skin and soft tissue infections.

Alternatives to penicillin for streptococcal infections include:

• Azithromycin 2 for pharyngitis/tonsillitis caused by Streptococcus pyogenes
• Clindamycin 3 for serious infections due to susceptible strains of streptococci, reserved for penicillin-allergic patients or when a penicillin is inappropriate.

From the Research

Alternatives to Penicillin for Streptococcal Infections

• For patients allergic to penicillin, alternatives such as erythromycin, clarithromycin, and azithromycin can be used to treat streptococcal pharyngitis/tonsillitis 4.
• Newer macrolides like clarithromycin and azithromycin offer lower rates of gastrointestinal complaints and more convenient dosing compared to erythromycin 4.
• First-generation cephalosporins are also options for patients with penicillin allergy 5, 6.
• Amoxicillin-clavulanate potassium is another alternative that can be used in patients who do not respond to initial treatment with penicillin 5.

Considerations for Antibiotic Selection

• Antibiotic selection should consider patients' allergies, bacteriologic and clinical efficacy, frequency of administration, duration of therapy, potential side effects, compliance, and cost 5.
• 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 6.
• Patient education may help to reduce recurrence of streptococcal pharyngitis 5.

Penicillin Allergy Evaluation

• Evaluation of penicillin allergy is important for antimicrobial stewardship, as many patients report allergies that may not be clinically significant 7.
• Direct amoxicillin challenge is appropriate for patients with low-risk allergy histories, while moderate-risk patients can be evaluated with penicillin skin testing 7.
• Clinicians should identify the methods supported by their available resources to evaluate penicillin allergy 7.

Resistance Patterns

• Patterns of antibiotic nonsusceptibility among invasive group A Streptococcus infections vary by site, year, risk factors, and emm type 8.
• Erythromycin-nonsusceptible and clindamycin-nonsusceptible strains are more frequent among certain emm types, such as types 77,58,11,83, and 92 8.
• Clinicians should consider local resistance patterns when treating invasive group A Streptococcus infections 8.