What is the recommended treatment for strep throat?

Treatment of Strep Throat

Penicillin or amoxicillin for 10 days is the recommended first-line treatment for streptococcal pharyngitis due to their proven efficacy, safety, narrow spectrum, and low cost. 1

First-Line Treatment Options

For Non-Penicillin Allergic Patients:

• Oral Penicillin V:

  • Adults: 250 mg 2-3 times daily for 10 days
  • Children: 250 mg 2-3 times daily for 10 days (for smaller children, dosing based on weight: 25-50 mg/kg/day divided into 2-3 doses)

• Oral Amoxicillin:

  • Adults: 500 mg twice daily or 250 mg three times daily for 10 days
  • Children: 25-50 mg/kg/day divided into 2-3 doses for 10 days
  • Often preferred in younger children due to better taste acceptance 1

• Intramuscular Benzathine Penicillin G:

  • Recommended for patients unlikely to complete the full 10-day oral course 1
  • Single dose administration ensures compliance

For Penicillin-Allergic Patients:

• First-generation cephalosporins (for those without anaphylactic sensitivity to penicillin):

  • Cephalexin: 500 mg twice daily for 10 days 1, 2

• Macrolides (for those with severe penicillin allergy):

  • Clarithromycin: 250 mg twice daily for 10 days
  • Azithromycin: 500 mg on day 1, then 250 mg daily for 4 more days (5-day course) 1

• Clindamycin: 300 mg three times daily for 10 days (especially effective for recurrent cases) 1

Important Clinical Considerations

Duration of Therapy

The full 10-day course of therapy is crucial for:

• Complete eradication of Group A Streptococcus (GAS) from the pharynx
• Prevention of acute rheumatic fever
• Prevention of suppurative complications

Despite some studies suggesting shorter courses with newer antibiotics, the IDSA guidelines strongly recommend maintaining the 10-day duration for most antibiotics to ensure complete eradication 1.

Compliance Challenges

• Penicillin failure rates have increased from 2-10% in the 1970s to approximately 30% more recently, with poor compliance being a major factor 3
• Twice-daily dosing of penicillin appears to be as effective as more frequent dosing, potentially improving compliance 4
• Once-daily dosing of penicillin is not recommended due to decreased efficacy 4

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or fever control 1
• Aspirin should be avoided in children due to risk of Reye's syndrome 1
• Corticosteroids are not recommended as adjunctive therapy 1

Special Situations

Recurrent Streptococcal Pharyngitis

For patients with multiple recurrences:

• Consider whether the patient is experiencing true recurrent infections or is a chronic carrier with viral infections 1
• For documented recurrences, consider:
  • Clindamycin or amoxicillin-clavulanate which have shown higher rates of streptococcal eradication in these cases 1
  • Intramuscular benzathine penicillin G if compliance with oral therapy is questionable 1

Follow-up Testing

• Routine post-treatment throat cultures or rapid antigen detection tests are not recommended 1
• Testing of asymptomatic household contacts is not routinely recommended 1

Common Pitfalls to Avoid

1. Insufficient treatment duration: Shortening the standard 10-day course increases risk of treatment failure and complications

2. Inappropriate antibiotic selection: Using broad-spectrum antibiotics when narrow-spectrum would suffice increases resistance risk and side effects

3. Overlooking compliance issues: Consider intramuscular benzathine penicillin G for patients unlikely to complete oral therapy

4. Treating viral pharyngitis with antibiotics: Ensure proper diagnosis of streptococcal pharyngitis before initiating antibiotics

5. Failing to recognize penicillin allergy severity: Distinguish between immediate hypersensitivity reactions (requiring avoidance of all β-lactams) and non-anaphylactic reactions (where cephalosporins may be used)

The evidence consistently supports penicillin or amoxicillin as first-line therapy for streptococcal pharyngitis, with appropriate alternatives for those with penicillin allergies. While newer antibiotics and shorter courses have been studied, the 10-day regimen of penicillin remains the gold standard for balancing efficacy, safety, and prevention of complications.