What is the recommended treatment for strep throat in children?

Treatment of Strep Throat in Children

Penicillin or amoxicillin for 10 days is the recommended first-line treatment for strep throat in children due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1

Diagnosis Before Treatment

Before initiating treatment, proper diagnosis is essential:

• Clinical features suggesting strep throat:

  • Sudden onset of sore throat
  • Fever
  • Headache
  • Tonsillopharyngeal inflammation
  • Patchy exudates
  • Tender anterior cervical lymph nodes
  • Age 5-15 years
  • Absence of cough, rhinorrhea, or hoarseness (which suggest viral etiology)

• Confirmation testing:

  • Rapid antigen detection test (RADT)
  • If RADT is negative in children, a backup throat culture is recommended 1
  • Testing generally not recommended in children <3 years unless they have risk factors (e.g., older sibling with strep throat) 1

First-Line Treatment Options

For children without penicillin allergy:

1. Oral Penicillin V 1

   • Dosage: 250 mg two or three times daily
   • Duration: 10 days
   • Recommendation strength: Strong, high-quality evidence

2. Oral Amoxicillin 1, 2

   • Dosage: 50 mg/kg once daily (maximum 1,000 mg)
   • Alternative: 25 mg/kg twice daily (maximum 500 mg per dose)
   • Duration: 10 days
   • Recommendation strength: Strong, high-quality evidence
   • Often preferred in young children due to better taste acceptance

3. Intramuscular Benzathine Penicillin G 1

   • Dosage: 600,000 units for children <60 lbs (27 kg); 1,200,000 units for ≥60 lbs
   • Single dose
   • Recommendation strength: Strong, high-quality evidence
   • Consider for patients unlikely to complete a full 10-day oral course

Alternative Treatment for Penicillin-Allergic Patients

For children with penicillin allergy:

1. For non-anaphylactic penicillin allergy 1

   • First-generation cephalosporins (e.g., cephalexin)
     • Dosage: 20 mg/kg twice daily (maximum 500 mg per dose)
     • Duration: 10 days
     • Recommendation strength: Strong, high-quality evidence

2. For anaphylactic penicillin allergy 1

   • Clindamycin

     • Dosage: 7 mg/kg three times daily (maximum 300 mg per dose)
     • Duration: 10 days
     • Recommendation strength: Strong, moderate-quality evidence

   • Azithromycin

     • Dosage: 12 mg/kg once daily (maximum 500 mg)
     • Duration: 5 days
     • Recommendation strength: Strong, moderate-quality evidence
     • Caution: Resistance to macrolides varies geographically 1, 3

   • Clarithromycin

     • Dosage: 7.5 mg/kg twice daily (maximum 250 mg per dose)
     • Duration: 10 days
     • Recommendation strength: Strong, moderate-quality evidence

Adjunctive Therapy

• Analgesics/antipyretics for symptom relief 1

  • Acetaminophen or NSAIDs for moderate to severe symptoms or high fever
  • Avoid aspirin in children due to risk of Reye syndrome

• Corticosteroids are not recommended as adjunctive therapy 1, 4

Important Considerations and Pitfalls

1. Treatment Duration: Complete the full 10-day course of antibiotics (except for 5-day azithromycin) even if symptoms resolve earlier, to prevent complications and ensure bacterial eradication 1

2. Compliance Challenges: The 10-day duration of penicillin therapy may lead to compliance issues, which is a major cause of treatment failure 5

   • Consider once-daily dosing when possible
   • Intramuscular benzathine penicillin G is an option for patients unlikely to complete oral therapy

3. Recurrent Infections: Patients with recurrent pharyngitis and laboratory evidence of Group A strep may be chronic carriers experiencing viral infections 1

   • Antibiotics generally not recommended for carriers except in specific situations

4. Follow-up: Routine post-treatment testing is not recommended unless symptoms persist 1

5. Household Contacts: Testing or treating asymptomatic household contacts is not routinely recommended 1

While some studies suggest shorter antibiotic courses (5-7 days) may be effective 6, 7, the most authoritative guidelines still recommend the standard 10-day course for penicillin and amoxicillin to ensure complete bacterial eradication and prevention of complications like rheumatic fever 1.