How to stop strep throat?

Treatment of Streptococcal Pharyngitis

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

First-Line Treatment Options

For Patients Without Penicillin Allergy:

1. Oral Options:

   • Penicillin V:

     • Children: 250 mg two or three times daily for 10 days
     • Adolescents/adults: 250 mg four times daily or 500 mg twice daily for 10 days 2, 1

   • Amoxicillin:

     • 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 2, 1

2. Parenteral Option:

   • Benzathine Penicillin G (intramuscular):
     • <60 lb (27 kg): 600,000 units as single dose
     • ≥60 lb (27 kg): 1,200,000 units as single dose 2, 1
     • Consider for patients unlikely to complete the full 10-day oral course 2

For Patients With Penicillin Allergy:

1. Non-Anaphylactic Allergy:

   • First-generation cephalosporins:
     • 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 2, 1
     • Avoid in patients with immediate hypersensitivity to β-lactam antibiotics 2

2. Anaphylactic Allergy:

   • Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 2, 1
   • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 2
   • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 2, 1

Important Treatment Considerations

Duration of Treatment

• The full 10-day course must be completed to prevent acute rheumatic fever, even if symptoms resolve earlier 2, 1, 3
• Skipping doses or not completing the full course may decrease treatment effectiveness and increase bacterial resistance 3

Symptom Management

• Acetaminophen or NSAIDs for pain and fever relief 1
• Avoid aspirin in children due to risk of Reye syndrome 1
• Warm salt water gargles may provide symptomatic relief 1

Treatment Failures and Recurrent Episodes

• For recurrent episodes, consider:
  • Clindamycin (20-30 mg/kg/day in 3 divided doses) for 10 days 1
  • Amoxicillin-clavulanate as an alternative option 1
  • Tonsillectomy for severe recurrent infections (≥7 episodes in past year, or ≥5 episodes per year for 2 consecutive years) 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: The full 10-day course is essential to prevent rheumatic fever 1, 3
2. Inappropriate antibiotic selection: Penicillin remains the drug of choice for non-allergic patients due to:
   • No documented resistance of Group A Streptococcus to penicillin 2
   • Narrow spectrum of activity reducing risk of resistance 1
   • Low cost 1
3. Unnecessary post-treatment testing: Follow-up cultures are not routinely indicated for asymptomatic patients who have completed therapy 2, 1
4. Treating asymptomatic carriers: Not generally recommended unless specific risk factors are present 1

Special Considerations

• Penicillin failure rates have increased over time, with some studies reporting rates of approximately 30% 4
• Primary causes of treatment failure include poor compliance with the 10-day regimen, reexposure to infected individuals, and penicillin tolerance 4
• While shorter antibiotic courses (5-7 days) have shown similar effectiveness in some studies 5, the standard 10-day course remains recommended by major guidelines to ensure eradication and prevent complications 2, 1

Remember that the goal of treatment is not just symptom resolution but prevention of complications like acute rheumatic fever, which requires complete eradication of Group A Streptococcus from the pharynx.