What is the recommended treatment for streptococcal pharyngitis?

Treatment of Streptococcal Pharyngitis

For patients with confirmed streptococcal pharyngitis, penicillin or amoxicillin is the recommended first-line treatment due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1

First-Line Treatment Options

For Patients Without Penicillin Allergy:

• Oral Penicillin V:

  • Children: 250 mg two or three times daily for 10 days
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily for 10 days
  • (Strong recommendation, high-quality evidence) 1

• Oral Amoxicillin:

  • 50 mg/kg once daily (maximum = 1,000 mg) for 10 days
  • Alternative: 25 mg/kg twice daily (maximum = 500 mg) for 10 days
  • (Strong recommendation, high-quality evidence) 1
  • Note: Amoxicillin is often preferred for young children due to better taste acceptance 1

• Intramuscular Benzathine Penicillin G (single dose):

  • < 60 lb (27 kg): 600,000 U
  • ≥ 60 lb: 1,200,000 U
  • (Strong recommendation, high-quality evidence) 1
  • Particularly useful for patients with anticipated poor adherence to oral therapy 1

For Patients With Penicillin Allergy:

• First-generation Cephalosporins (if not anaphylactically sensitive):

  • Cephalexin: 20 mg/kg twice daily (maximum = 500 mg per dose) for 10 days
  • Cefadroxil: 30 mg/kg once daily (maximum = 1 g) for 10 days
  • (Strong recommendation, high-quality evidence) 1

• Clindamycin:

  • 7 mg/kg three times daily (maximum = 300 mg per dose) for 10 days
  • (Strong recommendation, moderate-quality evidence) 1

• Macrolides (note: resistance concerns exist):

  • Azithromycin: 12 mg/kg once daily (maximum = 500 mg) for 5 days
  • Clarithromycin: 7.5 mg/kg twice daily (maximum = 250 mg per dose) for 10 days
  • (Strong recommendation, moderate-quality evidence) 1, 2

Adjunctive Therapy

• Analgesics/antipyretics (acetaminophen, NSAIDs) may be used for symptom relief and fever control 1
• Aspirin should be avoided in children due to risk of Reye syndrome 1
• Corticosteroids are not recommended 1

Special Considerations

Chronic Carriers

For patients with recurrent episodes of pharyngitis with positive Group A Streptococcus (GAS) tests who may be chronic carriers, antibiotics are generally not recommended unless:

1. Community outbreak of acute rheumatic fever or invasive GAS infection
2. Outbreak in a closed community
3. Personal/family history of acute rheumatic fever
4. Excessive anxiety about GAS infections
5. Tonsillectomy being considered solely for carrier state 1

For chronic carriers requiring treatment, recommended regimens include:

• Clindamycin (20-30 mg/kg/day in 3 doses for 10 days)
• Amoxicillin-clavulanate (40 mg/kg/day in 3 doses for 10 days) 1

Follow-up Recommendations

• Routine post-treatment testing is not recommended for asymptomatic patients 1
• Testing of asymptomatic household contacts is not routinely recommended 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: The full 10-day course of penicillin or amoxicillin must be completed to prevent rheumatic fever, even if symptoms resolve earlier 1

2. Inappropriate use of macrolides: Due to increasing resistance, macrolides should be reserved for patients with true penicillin allergy 1

3. Twice-daily dosing considerations: While twice-daily dosing of penicillin V (500 mg) is as effective as more frequent dosing, once-daily dosing of penicillin is associated with decreased efficacy and should not be used 3

4. Failure to distinguish carriers from acute infection: Patients with recurrent positive tests may be carriers experiencing viral infections rather than recurrent streptococcal infections 1

5. Overtreatment of viral pharyngitis: Testing is not recommended when clinical features strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers) 1

By following these evidence-based guidelines, clinicians can effectively treat streptococcal pharyngitis while minimizing complications, reducing antimicrobial resistance, and improving patient outcomes.