What is the recommended treatment for strep throat?

Treatment of Strep Throat

Penicillin V (500 mg orally 2-3 times daily for 10 days) or amoxicillin (50 mg/kg once daily, maximum 1000 mg, for 10 days) is the recommended first-line treatment for strep throat. 1

First-Line Treatment Options

• Penicillin V: 500 mg orally 2-3 times daily for 10 days (adults); 250 mg 2-3 times daily for children 1
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2

These medications remain the gold standard for treating Group A Streptococcal (GAS) pharyngitis due to their proven efficacy, safety profile, narrow spectrum of activity, and low cost. Most importantly, there has been no documented resistance of GAS to penicillins.

Alternative Treatment Options for Penicillin-Allergic Patients

For patients with penicillin allergy, treatment options depend on the type of allergy:

Non-Anaphylactic Allergy:

• Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1

Immediate Hypersensitivity or Anaphylactic Allergy:

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 3, 1
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 3, 1
• Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 3, 1

Important Note: Resistance of GAS to macrolides (azithromycin, clarithromycin) varies geographically and temporally, which may affect treatment efficacy 3.

Treatment Duration

A full 10-day course of antibiotics is critical to prevent rheumatic fever, even if symptoms resolve earlier 1. The only exception is azithromycin, which is given for 5 days due to its prolonged tissue concentration 1.

Studies have shown that shortened courses (5 days) of penicillin result in significantly higher recurrence rates (27%) compared to 10-day regimens (6%) 4, reinforcing the importance of completing the full treatment course.

Symptomatic Treatment

In addition to antibiotics, symptomatic relief can be provided with:

• NSAIDs (preferred over acetaminophen for better pain relief)
• Acetaminophen
• Warm salt water gargles
• Throat lozenges 1

Treatment for Chronic Carriers

For patients who are chronic carriers of GAS, more aggressive treatment regimens may be needed:

• Clindamycin: 20-30 mg/kg/day in three doses (maximum 300 mg per dose) for 10 days 3
• Penicillin with rifampin: Penicillin V for 10 days plus rifampin for the last 4 days 3
• Amoxicillin/clavulanate: 40 mg amoxicillin/kg/day in three doses for 10 days 3

Important Clinical Considerations

1. Contagiousness: Patients are considered non-contagious after 24 hours of appropriate antibiotic therapy 1

2. Treatment Failure: If penicillin treatment fails, consider:

   • Poor compliance with the 10-day regimen
   • Reexposure to infected individuals
   • Copathogenicity with other bacteria
   • Penicillin tolerance 5

3. Dosing Schedule: Twice-daily dosing of penicillin V (500 mg) is as effective as four-times-daily dosing and superior to once-daily dosing, which shows higher rates of persistent positive cultures 6

4. Follow-up: Routine follow-up is not necessary for uncomplicated cases, but patients should seek medical attention if symptoms persist or worsen 1

Pitfalls to Avoid

1. Undertreating: Failure to complete the full 10-day course increases risk of treatment failure and rheumatic fever 1

2. Overdiagnosis: Testing patients with clear viral symptoms (cough, rhinorrhea, hoarseness, oral ulcers) is not recommended 1

3. Inappropriate Antibiotic Selection: Using broad-spectrum antibiotics when narrow-spectrum would suffice contributes to antibiotic resistance

4. Inadequate Dosing: Once-daily penicillin dosing is less effective than twice or four times daily regimens 6

5. Ignoring Compliance Issues: Consider compliance factors when selecting treatment regimens, especially for children