What are the recommended antibiotics for streptococcal (strep) pharyngitis?

From the Guidelines

Penicillin V is the first-line antibiotic treatment for streptococcal pharyngitis, typically prescribed as 250-500 mg orally twice daily for 10 days in adults (children: 250 mg twice daily for those <27 kg, 500 mg twice daily for those ≥27 kg) 1.

Key Considerations

• For patients with penicillin allergy, alternatives include amoxicillin (500 mg twice daily for 10 days), first-generation cephalosporins like cephalexin (if no anaphylactic reaction to penicillin), or macrolides such as azithromycin (500 mg on day 1, then 250 mg daily for 4 more days) or clarithromycin (250 mg twice daily for 10 days) 1.
• Intramuscular benzathine penicillin G (1.2 million units as a single dose) is an option for patients with compliance concerns 1.
• Complete treatment is essential even if symptoms resolve quickly, as this prevents complications like rheumatic fever and reduces transmission 1.
• Penicillin remains the preferred choice because Group A Streptococcus has shown no resistance to it, while resistance to macrolides is increasing 1.
• Symptomatic relief with acetaminophen or ibuprofen can be used alongside antibiotics to manage pain and fever 1.

Special Situations

• For chronic carriers of Group A Streptococci, antimicrobial therapy may be indicated in certain situations, such as during a community outbreak of acute rheumatic fever or invasive GAS infection 1.
• In these cases, treatment regimens such as clindamycin, penicillin and rifampin, or amoxicillin-clavulanic acid may be effective in eliminating chronic streptococcal carriage 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 three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes)

The recommended antibiotics for streptococcal (strep) pharyngitis are:

• Penicillin (by the intramuscular route) as the usual drug of choice
• Azithromycin as an alternative to first-line therapy in individuals who cannot use first-line therapy 2
• Erythromycin is also an option for patients allergic to penicillin 3

From the Research

Recommended Antibiotics for Strep Pharyngitis

The following antibiotics are recommended for the treatment of streptococcal pharyngitis:

• Penicillin: 10 days of oral therapy or one injection of intramuscular benzathine penicillin is the treatment of choice due to its cost, narrow spectrum of activity, and effectiveness 4
• Amoxicillin: equally effective and more palatable than penicillin 4
• Erythromycin and first-generation cephalosporins: options in patients with penicillin allergy 4
• Azithromycin: a 3-day regimen has been shown to have similar clinical efficacy to a 10-day penicillin V regimen, but with lower bacteriologic eradication rates 5
• Cephalosporins: may provide higher bacteriologic eradication rates than penicillin V, and some (e.g. cefdinir and cefpodoxime proxetil) can be administered in a 5-day dosing schedule 6

Dosage and Administration

• Penicillin V: 250 mg four times daily or 500 mg twice daily for 10 days 7
• Azithromycin: 10 mg/kg once daily for 3 days 5
• Cephalosporins: dosage and administration vary depending on the specific medication and patient factors 6

Considerations for Treatment

• 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 4
• A strategy based on the use of a clinical diagnostic score, followed by a rapid test if the score is intermediate, seems to be the best way of restricting antibiotics to patients with pharyngitis due to group A streptococci 8
• Immediate antibiotic therapy is justified for patients with severe symptoms or signs of progression to locoregional suppuration, and when the local incidence of acute rheumatic fever is high 8