What is the management for strep (streptococcal) pharyngitis?

From the Guidelines

The management of strep pharyngitis primarily involves antibiotic therapy with penicillin as the first-line treatment, as recommended by the most recent and highest quality study 1.

Key Considerations

• The goal of treatment is to reduce symptom duration, prevent suppurative complications, and prevent rheumatic fever, which can cause long-term cardiac damage.
• For adults, the recommended regimen is either penicillin V 500 mg orally twice daily for 10 days or a single intramuscular injection of benzathine penicillin G 1.2 million units.
• For children, penicillin V is dosed at 250 mg twice daily for 10 days (for those weighing less than 27 kg) or the adult dose for heavier children.

Alternative Treatments

• In penicillin-allergic patients, alternatives include amoxicillin (50 mg/kg daily, maximum 1000 mg, for 10 days), first-generation cephalosporins (if no anaphylactic reaction to penicillin), or macrolides such as azithromycin (12 mg/kg daily, maximum 500 mg, for 5 days) or clarithromycin, as suggested by 1.
• Cephalexin is considered a second-line antibiotic due to its lower rate of relapse, good tolerability, and narrow spectrum 1.

Symptomatic Relief

• Symptomatic relief can be achieved with acetaminophen or ibuprofen for pain and fever.
• Patients should complete the full antibiotic course even if symptoms improve to prevent complications like rheumatic fever.

Return to Daily Activities

• Most individuals can return to school or work 24 hours after starting antibiotics when they are no longer contagious.

Importance of Antibiotics

• Antibiotics are important because they reduce symptom duration, prevent suppurative complications, and prevent rheumatic fever, which can cause long-term cardiac damage, as highlighted by 1 and 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 Because some strains are resistant to azithromycin, susceptibility tests should be performed when patients are treated with azithromycin. Data establishing efficacy of azithromycin in subsequent prevention of rheumatic fever are not available.

The management for strep (streptococcal) pharyngitis includes:

• Penicillin as the first-line therapy, administered intramuscularly, for the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever.
• Azithromycin as an alternative to first-line therapy in individuals who cannot use first-line therapy, with the note that it is often effective in the eradication of susceptible strains of Streptococcus pyogenes from the nasopharynx.
• Susceptibility tests should be performed when patients are treated with azithromycin, as some strains are resistant to it.
• The treatment should be adjusted accordingly once the results of the susceptibility tests become available 2.

From the Research

Management of Strep Pharyngitis

The management of strep pharyngitis typically involves antibiotic therapy. The choice of antibiotic and duration of treatment may vary depending on several factors, including the patient's age, medical history, and the presence of any underlying conditions.

Antibiotic Therapy

• Penicillin has been the traditional drug of choice for treating strep pharyngitis, with a dosage of 250 mg of penicillin V twice daily for 10 days being optimal for children 3.
• However, studies have shown that penicillin failure rates have increased over time, with rates ranging from 2-10% in the 1950s to approximately 30% in recent years 4.
• Alternative antibiotics, such as azithromycin and cephalosporins, have been shown to be effective in treating strep pharyngitis, with some studies suggesting that they may be superior to penicillin in certain cases 4, 5, 6.
• Azithromycin, in particular, has been shown to be a safe and effective alternative to penicillin, with a once-daily dosing regimen and a shorter duration of treatment 5, 6.

Treatment Duration and Compliance

• The traditional 10-day treatment regimen with penicillin has been shown to be effective in managing strep pharyngitis, but compliance can be a issue, particularly in areas where medical care is episodic 3.
• Shorter treatment regimens, such as 3-5 days, have been shown to be effective with alternative antibiotics, such as azithromycin and cephalosporins 4, 5.
• Compliance with antibiotic therapy is crucial to ensure effective treatment and prevent complications, such as rheumatic fever 3, 7.

Clinical Considerations

• The decision to start antibiotic therapy should be based on a clinical diagnostic score, followed by a rapid test if the score is intermediate 7.
• 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 7.
• In other situations, antibiotic therapy should be started only if symptoms do not begin to improve after 48 hours of symptomatic treatments 7.