What are the guidelines for streptococcal (strep) throat?

From the Guidelines

Strep throat guidelines recommend prompt diagnosis and treatment with antibiotics to prevent complications, with penicillin V being the first-line treatment for individuals without penicillin allergy, at a dose of 250 mg twice daily or 500 mg twice daily for 10 days, as recommended by the Infectious Diseases Society of America 1. The diagnosis of strep throat should be established through a rapid strep test or throat culture before starting antibiotics.

• For individuals without penicillin allergy, the recommended antibiotic regimens include:
  • Penicillin V, oral, at a dose of 250 mg twice daily or 500 mg twice daily for 10 days 1
  • Amoxicillin, oral, at a dose of 50 mg/kg once daily (max = 1000 mg) or 25 mg/kg (max = 500 mg) twice daily for 10 days 1
  • Benzathine penicillin G, intramuscular, at a dose of 600 000 U for individuals <27 kg or 1 200 000 U for individuals ≥27 kg, given as a single dose 1
• For individuals with penicillin allergy, alternative antibiotic regimens include:
  • Cephalexin, oral, at a dose of 20 mg/kg/dose twice daily (max = 500 mg/dose) for 10 days 1
  • Cefadroxil, oral, at a dose of 30 mg/kg once daily (max = 1 g) for 10 days 1
  • Clindamycin, oral, at a dose of 7 mg/kg/dose three times daily (max = 300 mg/dose) for 10 days 1
  • Azithromycin, oral, at a dose of 12 mg/kg once daily (max = 500 mg) for 5 days 1 Patients should complete the full antibiotic course, even if symptoms improve quickly, to prevent rheumatic fever and other complications 1. Symptomatic relief can be achieved with acetaminophen or ibuprofen for pain and fever, warm salt water gargles, and adequate hydration. Most patients can return to work or school 24 hours after starting antibiotics when they're no longer contagious. Antibiotics are important for strep throat because they reduce symptom duration, prevent spread, and most importantly, prevent serious complications like rheumatic heart disease and post-streptococcal glomerulonephritis 1.

From the FDA Drug Label

Prevention of Initial Attacks of Rheumatic Fever Penicillin is considered by the American Heart Association to be the drug of choice in the prevention of initial attacks of rheumatic fever (treatment of Streptococcus pyogenes infections of the upper respiratory tract e.g., tonsillitis, or pharyngitis). Erythromycin tablets are indicated for the treatment of penicillin-allergic patients. The therapeutic dose should be administered for ten days.

The guidelines for strep throat are as follows:

• Penicillin is the drug of choice for the prevention of initial attacks of rheumatic fever.
• For penicillin-allergic patients, erythromycin is an alternative treatment.
• The therapeutic dose of erythromycin should be administered for at least ten days 2.
• The American Heart Association suggests a dosage of 250 mg of erythromycin orally, twice a day in long-term prophylaxis of streptococcal upper respiratory tract infections for the prevention of recurring attacks of rheumatic fever in patients allergic to penicillin and sulfonamides 2.

From the Research

Guidelines for Strep Throat

• The diagnosis of strep throat is typically made using a throat culture or rapid antigen detection test 3, 4, 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 3.
• Penicillin and amoxicillin are recommended as first-line antibiotics for the treatment of strep throat, with a recommended course of 10 days 3, 4, 5.
• First-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 3, 5.
• Azithromycin and clarithromycin are not recommended due to significant resistance in some parts of the United States 5.
• Steroids are not recommended for symptomatic treatment 5.

Treatment Options

• Cephalosporins may be more effective than penicillin for symptom resolution, but the evidence is uncertain 6.
• Macrolides may not be more effective than penicillin for symptom resolution, and may have a higher risk of adverse events 6.
• Carbacephem may be more effective than penicillin for symptom resolution in adults and children, but the evidence is limited 6.
• Azithromycin may not be more effective than amoxicillin for symptom resolution, and may have a higher risk of adverse events 6.

Prevention and Complications

• Tonsillectomy is rarely recommended as a preventive measure, and is typically considered for patients with recurrent episodes of strep throat 3, 5.
• Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment should be reevaluated 5.
• The risk of complications, such as acute rheumatic fever and post-streptococcal glomerulonephritis, is low in high-income countries, but may be higher in low-income countries and Aboriginal communities 6.