From the Guidelines
The first line treatment for streptococcal pharyngitis is oral penicillin V (phenoxymethylpenicillin), typically prescribed as 250 mg twice daily for 10 days for children and 500 mg twice daily for 10 days for adolescents and adults. Alternatively, amoxicillin 50 mg/kg (maximum 1000 mg) once daily for 10 days is also effective and may be preferred due to better taste and improved compliance, especially in children 1. For patients with penicillin allergy, macrolides such as azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days) or clindamycin (7 mg/kg three times daily, maximum 300 mg per dose, for 10 days) are appropriate alternatives 1.
Key Considerations
- Complete treatment is essential even if symptoms resolve quickly, as this prevents complications like rheumatic fever and reduces transmission.
- Penicillin remains the first choice because Group A Streptococcus has never developed resistance to it, and it has a narrow spectrum of activity which minimizes disruption to normal gut flora and reduces the risk of antimicrobial resistance 1.
- The choice of antibiotic should consider factors such as efficacy, safety, antimicrobial spectrum, dosing schedule, and cost 1.
Treatment Options
- Oral penicillin V: 250 mg twice daily for 10 days for children and 500 mg twice daily for 10 days for adolescents and adults.
- Amoxicillin: 50 mg/kg (maximum 1000 mg) once daily for 10 days.
- Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days.
- Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days.
From the FDA Drug Label
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. The first line treatment for strep pharyngitis is penicillin by the intramuscular route, as it is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever 2.
From the Research
First Line Treatment for Strep Pharyngitis
The first line treatment for streptococcal pharyngitis typically involves the use of antibiotics to prevent complications and reduce the duration of symptoms.
- The recommended first-line therapy is a 10-day course of penicillin V, usually given 2 or 3 times per day 3.
- Alternative options include other penicillins, macrolides, and cephalosporins, with cephalosporins potentially offering higher bacteriologic eradication rates than penicillin V 3.
- For patients allergic to penicillin, first-generation cephalosporins, clindamycin, or macrolide antibiotics can be used as alternatives 4.
Antibiotic Options
- Penicillin and amoxicillin are considered first-line antibiotics, with a recommended course of 10 days 5.
- First-generation cephalosporins are recommended for patients with non-anaphylactic allergies to penicillin 5.
- Macrolides and cephalosporins can be effective alternatives, but their use should be considered in the context of antibiotic resistance and the potential for adverse events 6.