What is the recommended treatment for strep throat?

Treatment of Strep Throat

Penicillin remains the first-line treatment for strep throat due to its proven efficacy, safety, narrow spectrum, and low cost. 1, 2

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Use Centor criteria to assess likelihood of Group A Streptococcal (GAS) infection:

  • Fever history
  • Absence of cough
  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy 2

• Laboratory confirmation is recommended:

  • Rapid antigen detection test (RADT) for patients with 2+ Centor criteria
  • For children/adolescents with negative RADT, a throat culture should be performed
  • For adults with negative RADT, additional throat culture is not necessary 1, 2

• Testing is generally not recommended in children younger than 3 years unless specific risk factors exist 1

First-Line Treatment Options

For Non-Penicillin Allergic Patients:

1. Oral Penicillin V:

   • Children: 250 mg 2-3 times daily for 10 days
   • Adolescents/Adults: 250 mg 4 times daily or 500 mg twice daily for 10 days 1, 2

2. Amoxicillin (often preferred for children due to better taste):

   • 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2, 3
   • Studies suggest amoxicillin may have better bacteriologic cure rates than penicillin 4

3. Intramuscular Benzathine Penicillin G (for patients unlikely to complete oral therapy):

   • <60 lb (27 kg): 600,000 units as single dose
   • ≥60 lb (27 kg): 1,200,000 units as single dose 1

For Penicillin-Allergic Patients:

1. First-generation cephalosporins (if no immediate hypersensitivity to β-lactams):

   • 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 1

2. Clindamycin:

   • 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1

3. Macrolides (caution due to variable resistance):

   • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 5
   • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1

Important Treatment Considerations

• Duration: A full 10-day course of antibiotics is recommended to ensure bacterial eradication and prevent complications such as rheumatic fever 1, 2

• Shorter courses: While some newer agents have been studied for shorter durations, the standard 10-day course remains recommended for penicillin and most other antibiotics 1

• Dosing frequency: Twice-daily dosing of penicillin appears as effective as more frequent dosing, but once-daily dosing of penicillin is less effective and should be avoided 6

• Adjunctive therapy: Acetaminophen or NSAIDs can be used for pain and fever relief. Aspirin should be avoided in children due to risk of Reye syndrome. Corticosteroids are not recommended 2

Management of Treatment Failures

For patients with recurrent episodes:

• Consider clindamycin, amoxicillin-clavulanate, or benzathine penicillin G (with or without rifampin) 2
• If compliance is in question with oral therapy, consider intramuscular benzathine penicillin G 1

Follow-up

• No routine post-treatment testing is needed for asymptomatic patients 1
• Patients should return if symptoms worsen or fail to improve within 48-72 hours of antibiotic initiation 2

Pitfalls to Avoid

• Inadequate duration: Shortening the standard 10-day course may lead to treatment failure and complications
• Overtreatment: Antibiotics should only be prescribed for confirmed streptococcal pharyngitis, not viral infections
• Inappropriate follow-up testing: Routine post-treatment cultures are not recommended unless symptoms persist
• Neglecting compliance issues: Consider once-daily amoxicillin or intramuscular penicillin for patients with potential adherence problems

While some studies suggest cephalosporins may have better clinical outcomes than penicillin 7, penicillin remains the recommended first-line treatment due to its long track record of safety, efficacy, narrow spectrum, and low cost.