What alternative antibiotics can be given to a patient with a hypersensitivity reaction to amoxicillin (amoxicillin) for the treatment of streptococcal pharyngitis (strep)?

From the Guidelines

For a patient with a hypersensitivity reaction to amoxicillin, I strongly recommend azithromycin as the first alternative for the treatment of streptococcal pharyngitis, with a dosage of 12 mg/kg once daily (maximum 500 mg) for 5 days in children, and 500 mg on day 1, followed by 250 mg daily for days 2-5 in adults. This recommendation is based on the guidelines provided by the Infectious Diseases Society of America, which suggest that azithromycin is a suitable alternative for patients with penicillin allergy 1. Other options, such as clindamycin and clarithromycin, may also be considered, but azithromycin is generally preferred due to its efficacy and safety profile. It is essential to note that cephalosporins, like cephalexin, should be avoided in patients with a history of anaphylactic reactions to penicillin, but may be considered in those with non-severe, non-anaphylactic penicillin allergy. The patient should complete the full course of antibiotics, even if symptoms improve quickly, to prevent complications like rheumatic fever. Additionally, the patient should rest, stay hydrated, use throat lozenges, and take acetaminophen or ibuprofen for pain and fever as needed.

Some key points to consider when treating streptococcal pharyngitis in patients with amoxicillin hypersensitivity include:

• The importance of completing the full course of antibiotics to prevent complications
• The need to choose an alternative antibiotic that is effective against Group A Streptococcus
• The consideration of the patient's allergy history and the potential for cross-reactivity with other antibiotics
• The use of adjunctive therapies, such as pain management and hydration, to support the patient's recovery

It is crucial to prioritize the patient's safety and well-being when selecting an alternative antibiotic, and to choose an option that is supported by strong, high-quality evidence, such as the guidelines provided by the Infectious Diseases Society of America 1.

From the FDA Drug Label

Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy Azithromycin is often effective in the eradication of susceptible strains of Streptococcus pyogenes from the nasopharynx

Alternative antibiotic for streptococcal pharyngitis: Azithromycin can be given to patients with a hypersensitivity reaction to amoxicillin for the treatment of streptococcal pharyngitis (strep) as an alternative to first-line therapy.

• Key points:
  • Azithromycin is effective in eradicating susceptible strains of Streptococcus pyogenes from the nasopharynx.
  • Susceptibility tests should be performed when patients are treated with azithromycin due to potential resistance. 2

From the Research

Alternative Antibiotics for Streptococcal Pharyngitis

In cases where a patient has a hypersensitivity reaction to amoxicillin, alternative antibiotics can be used to treat streptococcal pharyngitis. The following options are available:

• Azithromycin: A total dose of 60 mg/kg azithromycin, given either as 12 mg/kg once daily for 5 days or 20 mg/kg once daily for 3 days, provides the best rate of GABHS eradication 3.
• First-generation cephalosporins: These can be used as an alternative to penicillin in patients allergic to penicillin 4.
• Clindamycin: This antibiotic can be used in patients allergic to penicillin 4.
• Macrolide antibiotics: These can be used in patients allergic to penicillin, but resistance to macrolides has been identified in some geographic regions 5.
• Cefdinir: A third-generation cephalosporin that can be administered in a 5-day dosing schedule, making it a convenient alternative to penicillin V 5.

Dosage and Administration

The dosage and administration of these alternative antibiotics vary:

• Azithromycin: 12 mg/kg once daily for 5 days or 20 mg/kg once daily for 3 days 3.
• Cefdinir: Approved for use in a 5-day dosing schedule 5.
• Macrolide antibiotics: Typically administered once daily, with a standard regimen of 10 mg/kg/day for 3 days or 10 mg/kg on the first day, followed by 5 mg/kg/day for a further 4 days 6.

Efficacy and Safety

The efficacy and safety of these alternative antibiotics have been studied:

• Azithromycin: Appears to be a safe and effective alternative treatment for streptococcal pharyngitis in adult outpatients, with a 91% eradication rate of GABHS 7.
• Cefdinir: Offers a convenient 5-day dosing schedule and may provide somewhat higher bacteriologic eradication rates than penicillin V 5.
• Macrolide antibiotics: Generally well tolerated, with mostly gastrointestinal adverse events that are mild to moderate in severity 6.