What is the recommended treatment for a patient with a strep (streptococcal) positive test?

Treatment for Strep Positive Pharyngitis

Penicillin remains the treatment of choice for strep pharyngitis due to its proven efficacy, safety, narrow spectrum, and low cost, with a standard 10-day course required to prevent complications like acute rheumatic fever. 1, 2

First-Line Treatment Options

For Non-Penicillin Allergic Patients:

• Penicillin V:
  • Adults: 250 mg 3-4 times daily or 500 mg twice daily for 10 days 2
  • Children: Weight-based dosing for 10 days 2
• Amoxicillin (equally effective, better taste acceptance in children):
  • Adults: 500 mg twice daily or 1000 mg once daily for 10 days 2, 3
  • Children: 50 mg/kg/day in divided doses every 12 hours or 20 mg/kg/day in divided doses every 8 hours for 10 days 3
• Benzathine penicillin G (intramuscular, single dose):
  • Patients <60 lb (27 kg): 600,000 units
  • Patients >60 lb: 1,200,000 units 2
  • Consider for patients unlikely to complete the full 10-day oral course 2

For Penicillin-Allergic Patients:

• Non-anaphylactic allergy:
  • First-generation cephalosporins (e.g., cephalexin) for 10 days 1, 2
• Anaphylactic allergy:
  • Clindamycin: 7 mg/kg three times daily (max 300 mg per dose) for 10 days 2
  • Clarithromycin: 7.5 mg/kg twice daily (max 250 mg per dose) for 10 days 2
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 2

Important Treatment Considerations

Duration of Therapy

• A full 10-day course is critical for most antibiotics to achieve maximal pharyngeal eradication of group A streptococci and prevent acute rheumatic fever, even if symptoms resolve earlier 1, 2, 3
• Exceptions with FDA approval for shorter courses:
  • Azithromycin: 5-day course (due to prolonged tissue half-life) 1, 2
  • Cefdinir and cefpodoxime: 5-day courses 1

Treatment Failures

• If symptoms persist or worsen after 5 days of appropriate treatment, consider:

  • Non-compliance with the prescribed regimen 1
  • Penicillin treatment failure (occurs in 5-35% of cases) 4
  • New infection with group A streptococci 1
  • Viral pharyngitis in a streptococcal carrier 1

• For documented treatment failures:

  • Consider cephalosporins or azithromycin 4
  • Clindamycin or amoxicillin-clavulanic acid for 10 days 2

Follow-up and Testing

• Routine post-treatment throat cultures or rapid antigen detection tests (RADT) are not recommended 1, 2
• Testing or treatment of asymptomatic household contacts is not routinely recommended 1, 2

Recurrent Infections

• For patients with multiple, recurrent episodes meeting Paradise criteria (≥7 episodes in the past year, ≥5 episodes per year for 2 consecutive years, or ≥3 episodes per year for 3 consecutive years), consider tonsillectomy 2, 5

Adjunctive Therapy

• Pain and fever management with acetaminophen or NSAIDs (avoid aspirin in children due to risk of Reye syndrome) 2
• Topical remedies such as lozenges and warm salt water gargles for symptomatic relief 2

Clinical Pearls

• Penicillin resistance in Group A Streptococcus has never been documented 1
• BID dosing of penicillin is as effective as more frequent dosing regimens, which may improve compliance 6
• Once-daily amoxicillin (50 mg/kg, max 1000 mg) for 10 days has been shown to be effective and may improve adherence 1
• Patients should be advised to complete the full course of antibiotics even if symptoms improve, to prevent complications and reduce the risk of developing antibiotic resistance 3, 7