From the Guidelines
Penicillin V is the first-line treatment for streptococcal throat (strep throat) in children, with a recommended dosage of 250 mg twice daily for children weighing less than 27 kg and 500 mg twice daily for children weighing 27 kg or more, for a duration of 10 days, as stated in the 2012 update by the Infectious Diseases Society of America 1. The choice of penicillin is due to its proven efficacy, safety, narrow spectrum, and low cost, as well as the fact that Group A Streptococcus has never developed resistance to it 1. Alternatively, amoxicillin can be used at a dose of 50 mg/kg once daily (maximum 1000 mg) for 10 days, which some children may find more palatable, as noted in the guidelines 1. For children with penicillin allergy, narrow-spectrum cephalosporins like cephalexin are preferred if the allergy is non-anaphylactic, with a dosage of 20 mg/kg/dose twice daily (max = 500 mg/dose) for 10 days, as recommended in the guidelines 1. In cases of severe penicillin allergy, macrolides such as azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days) can be used, though resistance rates are higher, as mentioned in the guidelines 1. Some key points to consider when treating strep throat in children include:
- Complete adherence to the full course of antibiotics is essential, even if symptoms improve quickly, to prevent complications like rheumatic fever and post-streptococcal glomerulonephritis.
- Penicillin remains the first choice because Group A Streptococcus has never developed resistance to it, and it has a narrow spectrum that minimizes disruption to the normal gut flora, as noted in the guidelines 1.
- The diagnosis of streptococcal pharyngitis should be established through accurate diagnosis, followed by appropriate antimicrobial therapy, to prevent acute rheumatic fever and other complications, as emphasized in the guidelines 1.
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 throat in children is penicillin by the intramuscular route, as it is the usual drug of choice for the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever 2.
From the Research
First-Line Treatment for Strep Throat in Children
The first-line treatment for strep throat in children is a 10-day course of penicillin V, usually given 2 or 3 times per day 3. This treatment is recommended to prevent acute rheumatic fever and suppurative complications, hasten resolution of clinical signs and symptoms, and prevent transmission to close contacts.
Alternative Treatments
Alternative treatments to penicillin V include other penicillins, macrolides, and cephalosporins 3, 4. Cephalosporins, such as cefdinir and cefpodoxime proxetil, may provide higher bacteriologic eradication rates than penicillin V and can be administered in a 5-day dosing schedule 3. Macrolides, such as azithromycin and clarithromycin, offer convenient dosing and lower rates of gastrointestinal complaints, but may not be as effective in eradicating streptococcal infections in areas with high resistance rates 5, 4, 6.
Key Points to Consider
- Penicillin V is the recommended first-line treatment for strep throat in children 3
- Alternative treatments, such as cephalosporins and macrolides, may be considered in cases of penicillin allergy or resistance 3, 4
- A 10-day course of treatment is typically recommended, but shorter courses of certain antibiotics, such as azithromycin, may be effective in some cases 5, 6
- The choice of antibiotic should be based on the child's medical history, the severity of the infection, and the likelihood of resistance in the community 3, 6
Duration of Treatment Before Return to School
Children with strep throat may be able to return to school as little as 12 hours after starting antibiotic treatment, provided they are afebrile and improved 7. A single dose of amoxicillin has been shown to be effective in reducing the detection of group A Streptococci (GAS) on throat cultures, with 91% of children having no detectable GAS on the morning of day 2 7.