From the Guidelines
For a patient with Group A beta-hemolytic streptococcal (GABHS) throat infection who also has Epstein-Barr virus (EBV) infection, alternatives to amoxicillin should be used to prevent the side effect of a diffuse maculopapular rash. The preferred alternatives include azithromycin (500 mg on day 1, then 250 mg daily for 4 more days), clarithromycin (250 mg twice daily for 10 days), or clindamycin (300 mg three times daily for 10 days) as recommended by the Infectious Diseases Society of America 1. Cephalosporins like cephalexin (500 mg twice daily for 10 days) are also effective options. These alternatives are recommended because amoxicillin and ampicillin can cause a diffuse maculopapular rash in up to 90% of patients with active EBV infection, which is not a true allergy but rather an interaction between the antibiotic and the viral infection 1. The rash typically appears 3-5 days after starting the medication and can be extensive and uncomfortable. Treating GABHS throat infection is important even with concurrent EBV to prevent complications like rheumatic fever and post-streptococcal glomerulonephritis. Patients should complete the full course of antibiotics even if symptoms improve before completion. Some key points to consider when selecting an antimicrobial for treatment of GAS pharyngitis include efficacy, safety, antimicrobial spectrum, dosing schedule, compliance with therapy, and cost 1. Penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents, but for penicillin-allergic individuals, a first-generation cephalosporin, clindamycin, clarithromycin, or azithromycin may be used 1. It is essential to note that the treatment of GAS pharyngitis in penicillin-allergic individuals should be chosen carefully to avoid potential allergic reactions and ensure effective treatment. The Infectious Diseases Society of America provides guidelines for the diagnosis and management of Group A streptococcal pharyngitis, which include recommendations for antibiotic treatment and prevention of complications 1.
Key Considerations
- Efficacy of the antibiotic
- Safety profile of the antibiotic
- Antimicrobial spectrum of the antibiotic
- Dosing schedule and compliance with therapy
- Cost of the antibiotic
- Potential for allergic reactions in penicillin-allergic individuals
Recommended Alternatives to Amoxicillin
- Azithromycin (500 mg on day 1, then 250 mg daily for 4 more days)
- Clarithromycin (250 mg twice daily for 10 days)
- Clindamycin (300 mg three times daily for 10 days)
- Cephalosporins like cephalexin (500 mg twice daily for 10 days)
From the FDA Drug Label
Pharyngitis/Tonsillitis 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)
Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS):
Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS
Day 14Day 30
Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%)
Penicillin V242/332 (73%)206/325 (63%)
Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%)
Penicillin V284/338 (84%)241/325 (74%)
Alternative to Amoxicillin: Azithromycin can be used as an alternative to amoxicillin for the treatment of GABHS throat infection.
- Dosage: 12 mg/kg once a day for 5 days
- Efficacy: Azithromycin has been shown to be clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30
- Side Effects: The most common side effects were diarrhea/loose stools, vomiting, and abdominal pain 2 2
From the Research
Alternatives to Amoxicillin for GABHS Throat Infection in Patients with Epstein-Barr Virus Infection
To prevent the side effects of giving amoxicillin for a throat infection in case of Epstein-Barr nucleosis, alternative antibiotics can be considered. The following options are available:
- Penicillin: As recommended by the American Academy of Pediatrics and American Heart Association, penicillin is the first-line therapy for GABHS infections 3.
- Erythromycin: For patients allergic to penicillin, erythromycin is a suitable alternative 3.
- Cephalosporins: Cephalosporins, such as cefpodoxime, are effective against GABHS and can be used as an alternative to penicillin 3, 4.
- Azithromycin: Azithromycin is a macrolide antibiotic that has been shown to be effective in treating GABHS infections and can be used as an alternative to penicillin 3, 5.
- Cefprozil: Cefprozil is a cephalosporin antibiotic that has been shown to have a lesser inhibitory effect on alpha-hemolytic streptococci, making it a potential alternative for GABHS eradication 6.
Considerations for Antibiotic Resistance
When choosing an alternative antibiotic, it is essential to consider the resistance patterns of GABHS.
- Erythromycin resistance has been reported in some countries, but it is not a significant problem in the United States 7.
- Penicillin resistance has not been a significant issue, with GABHS remaining susceptible to penicillin after decades of use 7.
- Tetracyclines and sulfonamides are not recommended due to high resistance rates and ineffectiveness in eradicating GABHS 7.
- Cephalosporins and macrolides, such as azithromycin, are effective against GABHS and can be used as alternatives to penicillin 3, 5, 7.