What are alternative treatments for streptococcal pharyngitis in a patient with a penicillin (PCN) allergy?

From the Guidelines

For patients allergic to penicillin, the recommended alternative treatment for strep pharyngitis is azithromycin, with a typical regimen of 12 mg/kg once daily (max = 500 mg) for 5 days 1. This recommendation is based on the strongest and most recent evidence from the Infectious Diseases Society of America's 2012 clinical practice guideline for the diagnosis and management of Group A streptococcal pharyngitis 1.

Alternative Treatment Options

If azithromycin is not suitable, other options include:

• Cephalexin, 20 mg/kg/dose twice daily (max = 500 mg/dose) for 10 days, but this should be avoided in individuals with immediate type hypersensitivity to penicillin 1
• Clindamycin, 7 mg/kg/dose three times daily (max = 300 mg/dose) for 10 days 1
• Clarithromycin, 7.5 mg/kg/dose twice daily (max = 250 mg/dose) for 10 days 1 These antibiotics are effective against Group A Streptococcus, the bacteria causing strep throat.

Important Considerations

Patients should complete the full course of antibiotics even if symptoms improve. They should also be advised to stay hydrated, rest, and use over-the-counter pain relievers if needed for symptom relief. If symptoms worsen or do not improve after 48-72 hours of treatment, they should follow up with their healthcare provider. Local resistance patterns should be considered when selecting an antibiotic, as resistance to certain agents can vary geographically and temporally 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 In the treatment of streptococcal infections of the upper respiratory tract (e.g., tonsillitis or pharyngitis), the therapeutic dosage of erythromycin should be administered for at least ten days.

Alternative treatments for streptococcal pharyngitis in a patient with a penicillin (PCN) allergy are:

• Azithromycin 2
• Erythromycin 3

These treatments can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy.

From the Research

Alternative Treatments for Streptococcal Pharyngitis

In patients with a penicillin (PCN) allergy, alternative treatments for streptococcal pharyngitis include:

• Azithromycin: a macrolide antibiotic that can be given once daily for 5 days 4, 5, 6, 7
• Clarithromycin: a macrolide antibiotic that can be given twice daily 5
• Erythromycin: a macrolide antibiotic that can be given twice daily for 10 days 5, 7
• Cephalosporins: a class of antibiotics that can be used as an alternative to penicillin, with simpler and/or short-course regimens available 8

Advantages of Alternative Treatments

The alternative treatments have several advantages, including:

• Simpler and shorter dosing regimens compared to penicillin V 4, 5, 7
• Lower rates of gastrointestinal complaints compared to erythromycin 5
• Effective eradication of group A beta-hemolytic streptococci (GABHS) 4, 6
• Suitable for patients who are allergic to penicillin or have failed therapy with a beta-lactam 4, 5, 8, 7

Considerations for Treatment

When considering alternative treatments, it is essential to weigh the convenience and efficacy of these regimens against their higher cost and broader spectrum of antimicrobial activity compared to penicillin 7. Additionally, patient compliance and the potential for adverse events should be taken into account 6.