What is the recommended treatment for a 24-year-old male with streptococcal pharyngitis (strep)?

Treatment for Streptococcal Pharyngitis in a 24-Year-Old Male

For a 24-year-old male with streptococcal pharyngitis, oral penicillin V (250 mg four times daily or 500 mg twice daily for 10 days) is the recommended first-line treatment due to its proven efficacy, safety, narrow spectrum, and low cost. 1

Diagnostic Confirmation

Before initiating treatment, confirm the diagnosis with:

• Rapid antigen detection test (RADT)
• If RADT is negative in adults, backup culture is generally not necessary due to low incidence of illness and risk of rheumatic fever 1

First-Line Treatment Options (Non-Penicillin Allergic Patients)

1. Penicillin V (oral):

   • 250 mg four times daily OR 500 mg twice daily
   • Duration: 10 days
   • Strength of recommendation: Strong, high-quality evidence 1

2. Amoxicillin (oral):

   • 1000 mg once daily OR 500 mg twice daily
   • Duration: 10 days
   • Strength of recommendation: Strong, high-quality evidence 1
   • Note: Often preferred due to better taste and once/twice daily dosing

3. Penicillin G benzathine (intramuscular):

   • 1,200,000 U single dose (for patients ≥60 lb/27 kg)
   • Strength of recommendation: Strong, high-quality evidence 1
   • Consider for patients unlikely to complete full oral course

Alternative Treatment Options (Penicillin-Allergic Patients)

1. Non-anaphylactic penicillin allergy:

   • Cephalexin: 500 mg twice daily for 10 days
   • Cefadroxil: 1 g once daily for 10 days
   • Strength of recommendation: Strong, high-quality evidence 1

2. Anaphylactic penicillin allergy:

   • Clindamycin: 300 mg three times daily for 10 days
   • Clarithromycin: 250 mg twice daily for 10 days
   • Azithromycin: 500 mg on day 1, then 250 mg daily for 4 days
   • Strength of recommendation: Strong, moderate-quality evidence 1

Important Considerations

• Complete the full course: Even if symptoms improve, complete the full 10-day course to prevent complications like rheumatic fever 1

• Macrolide resistance: Resistance of Group A streptococcus to azithromycin and clarithromycin varies geographically and temporally 1, 2

• Symptom management: Acetaminophen or NSAIDs may be used for fever and pain relief 1

• Avoid corticosteroids: Adjunctive corticosteroid therapy is not recommended 1

• Follow-up: Post-treatment testing is not routinely recommended unless symptoms persist 1

When to Re-evaluate

Re-evaluate if:

• Symptoms worsen after starting antibiotics
• Symptoms persist for 5 days after starting treatment 2

Recurrent Episodes

For patients with recurrent episodes, consider:

• Confirming compliance with previous treatment
• Using intramuscular benzathine penicillin G if compliance is questionable
• For true recurrences, clindamycin may be more effective at eradicating pharyngeal streptococci 1

Despite some studies showing higher failure rates with penicillin compared to newer antibiotics 3, guidelines still strongly recommend penicillin or amoxicillin as first-line therapy due to their proven efficacy in preventing complications, narrow spectrum of activity, and low cost 1.