What is the recommended treatment for strep throat?

Treatment of Strep Throat

Penicillin or amoxicillin is the first-line treatment for strep throat due to their narrow spectrum of activity, infrequency of adverse reactions, modest cost, and proven efficacy. 1

First-Line Treatment Options

Penicillin V

• Adults: 500 mg 2-3 times daily for 10 days 1
• Children: 250 mg 2-3 times daily for 10 days 1
• The standard 10-day duration is recommended to prevent acute rheumatic fever 1

Amoxicillin

• Children: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2
• Often preferred for young children due to better palatability 1
• FDA-approved for treatment of streptococcal infections 2

Alternative Treatment 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

Anaphylactic Penicillin Allergy

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 3
• Clarithromycin: For patients with severe penicillin allergy 1

Symptom Management

• Ibuprofen (preferred): 400 mg every 6-8 hours as needed 1
• Acetaminophen: 500-1000 mg every 4-6 hours as needed 1
• Avoid aspirin in children due to risk of Reye syndrome 1

Important Clinical Considerations

1. Testing Recommendations:

   • Use Centor Criteria to guide testing decisions
   • Score ≥2 indicates need for rapid antigen detection test or throat culture 1
   • Testing not recommended for children <3 years old 1

2. Duration of Treatment:

   • Standard duration is 10 days for most antibiotics to prevent acute rheumatic fever 1
   • Exception: Azithromycin is given for 5 days due to its longer half-life 1, 3

3. Return to Normal Activities:

   • Patients are considered non-contagious after 24 hours of antibiotic therapy 1
   • Symptoms typically improve within 24-48 hours after starting treatment 1

4. Follow-up:

   • Routine post-treatment throat cultures are not recommended 1
   • For recurrence shortly after treatment completion, retreatment with the same antibiotic or alternative therapies may be considered 1

Treatment Challenges

• Penicillin treatment failure rates have increased over time, potentially due to:

  • Poor compliance with the 10-day regimen 4
  • Reexposure to infected individuals 4
  • Copathogenicity with other bacteria 4

• While some studies suggest cephalosporins may provide better bacterial eradication rates than penicillin 4, 5, current guidelines still recommend penicillin or amoxicillin as first-line therapy due to their proven efficacy, safety profile, and lower cost 1.

Special Populations

• For patients with multiple recurrences, investigation for chronic carriers in the household may be necessary 1
• For severe renal impairment (GFR <30 mL/min), dosage adjustments are required for amoxicillin 2

Remember that the primary goal of treatment is to prevent complications like acute rheumatic fever, hasten symptom resolution, and prevent transmission to others.