What are the recommended antibiotics for treating bacterial sore throat, specifically Group A beta-hemolytic streptococcus (GABHS) infections?

From the Guidelines

Penicillin V is the first-line antibiotic treatment for Group A beta-hemolytic streptococcus (GABHS) throat infections. For adults, the recommended dosage is 250 mg orally twice daily or 500 mg orally twice daily for 10 days, as stated in the 2012 IDSA guideline 1. For children, the dosage is 250 mg orally twice daily for those weighing ≥27 kg, or 250 mg orally two to three times daily for 10 days. Amoxicillin is an acceptable alternative, particularly for children, due to its better taste and once-daily dosing option (50 mg/kg, maximum 1000 mg, once daily for 10 days) 1.

Key Considerations

• For patients with penicillin allergy, alternatives include first-generation cephalosporins (if no history of anaphylaxis to penicillin), clindamycin (300 mg orally three times daily for 10 days), azithromycin (500 mg on day 1, then 250 mg daily for 4 days), or clarithromycin (250 mg orally twice daily for 10 days) 1.
• The full 10-day course should be completed even if symptoms resolve earlier to prevent complications like rheumatic fever.
• Penicillin remains the preferred treatment because GABHS has never developed resistance to it, and it has a narrow spectrum that minimizes disruption to normal gut flora, reducing the risk of antibiotic-associated diarrhea and antimicrobial resistance.

Additional Guidance

• The 2016 American College of Physicians and the Centers for Disease Control and Prevention guideline also recommends testing patients with symptoms suggestive of group A streptococcal pharyngitis and treating patients with antibiotics only if they have confirmed streptococcal pharyngitis 1.
• The European Society for Clinical Microbiology and Infectious Diseases guideline recommends using the Centor clinical scoring system or rapid antigen test to diagnose group A streptococcal infection and treating with penicillin V, twice or three times daily for 10 days, if antibiotics are indicated 1.

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%)

The recommended antibiotics for treating bacterial sore throat, specifically Group A beta-hemolytic streptococcus (GABHS) infections, are:

• Azithromycin: 12 mg/kg once a day for 5 days
• Penicillin V: 250 mg three times a day for 10 days Azithromycin is clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30, with a bacteriologic eradication rate of 95% at Day 14 and 77% at Day 30, and a clinical success rate of 98% at Day 14 and 94% at Day 30 2

From the Research

Recommended Antibiotics for GABHS Infections

The choice of antibiotics for treating bacterial sore throat, specifically Group A beta-hemolytic streptococcus (GABHS) infections, is crucial for effective management and prevention of complications. The following antibiotics are recommended:

• Penicillin V for 10 days is the standard therapy and is effective in the management of GABHS pharyngitis 3, 4, 5, 6
• Azithromycin is an alternative treatment to standard penicillin therapy, especially in cases of penicillin hypersensitivity or when patient nonadherence to a 10-day penicillin regimen is suspected 3, 4
• Cephalosporins, such as cefpodoxime and cefdinir, are also effective alternatives to penicillin V, with the advantage of simpler and shorter dosing regimens 4, 6
• Clarithromycin is another option, with clinical and bacteriologic efficacy comparable to penicillin 7
• Erythromycin is recommended for patients allergic to penicillin 4

Important Considerations

When choosing an antibiotic, it is essential to consider the following factors:

• The patient's allergy history and potential hypersensitivity to penicillin or other antibiotics
• The patient's ability to adhere to the prescribed treatment regimen
• The risk of bacteriologic treatment failures, which can occur with penicillin V therapy 3, 4
• The potential for antibiotic resistance, particularly to macrolides and tetracyclines 5
• The importance of preventing rheumatic fever and other complications associated with GABHS infections 3, 4, 6