What antibiotics are recommended for treating streptococcal (strep) pharyngitis in India?

Antibiotic Treatment for Strep Pharyngitis in India

Penicillin V or amoxicillin should be used as first-line treatment for streptococcal pharyngitis in India, with a 10-day course being essential to prevent rheumatic fever, which remains a significant concern in the region. 1, 2

First-Line Treatment Options

Oral Options:

• 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 1

• Amoxicillin (often preferred due to better taste and compliance):

  • 50 mg/kg once daily (maximum 1,000 mg) for 10 days
  • Alternative: 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2

Parenteral Option:

• Benzathine Penicillin G (single intramuscular injection):
  • <60 lb (27 kg): 600,000 units
  • ≥60 lb (27 kg): 1,200,000 units 1

Second-Line Treatment Options (for penicillin-allergic patients)

Non-anaphylactic Penicillin Allergy:

• First-generation cephalosporins (e.g., cephalexin):
  • 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1

Immediate-type/Severe Penicillin Allergy:

• Clindamycin:

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

• Clarithromycin:

  • 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1

• Azithromycin:

  • 12 mg/kg once daily (maximum 500 mg) for 5 days 1
  • Note: Azithromycin has shown lower bacteriological eradication rates compared to penicillin (38% vs 81%) despite similar clinical success rates 3

Important Considerations for India

1. Complete the full course: The 10-day duration for penicillin/amoxicillin is critical in India where rheumatic fever remains a significant concern 1, 2

2. Antimicrobial resistance: While penicillin resistance in Group A Streptococcus has not been documented worldwide, macrolide resistance varies geographically 1

3. Avoid tetracyclines and sulfonamides: These have higher resistance rates among Group A streptococci and frequently fail to eradicate even susceptible organisms 1

4. Diagnostic confirmation: Whenever possible, confirm diagnosis with rapid antigen detection test or throat culture before initiating antibiotics 2

Treatment Algorithm

1. Confirm diagnosis using clinical criteria (Centor criteria) and laboratory testing when available
2. For non-allergic patients: Start penicillin V or amoxicillin for 10 days
3. For penicillin-allergic patients:
   • Non-anaphylactic allergy: First-generation cephalosporins for 10 days
   • Anaphylactic allergy: Clindamycin, clarithromycin, or azithromycin

Pitfalls to Avoid

1. Shortened treatment duration: While shorter courses (3-5 days) of newer antibiotics like azithromycin are convenient, they may have higher bacteriological failure rates and should be avoided in regions with high rheumatic fever prevalence 4

2. Overtreatment of viral pharyngitis: Not all sore throats require antibiotics; clinical scoring systems help identify patients likely to have streptococcal infection 2

3. Inadequate follow-up: While routine post-treatment testing is not recommended, patients should return if symptoms worsen or fail to improve within 48-72 hours 2

4. Treating carriers: Asymptomatic carriers generally don't require treatment unless specific risk factors exist 1

By following these evidence-based recommendations, clinicians in India can effectively treat streptococcal pharyngitis while minimizing complications and antibiotic resistance.