What is the recommended treatment for strep throat?

Treatment of Streptococcal Pharyngitis

Penicillin V or amoxicillin for 10 days is the first-line treatment for streptococcal pharyngitis, with strong evidence supporting this approach to prevent complications such as rheumatic fever. 1

First-Line Antibiotic Selection

• For patients with no penicillin allergy:

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

• Key point: Completing the full 10-day course is essential to prevent rheumatic fever, ensure complete eradication of Group A Streptococcus, and reduce risk of treatment failure 1

Alternative Antibiotics for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy:

  • Cephalexin or cefadroxil for 10 days 1

• For anaphylactic penicillin allergy:

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

• Caution: Macrolides (azithromycin, clarithromycin) should be reserved for penicillin-allergic patients due to increasing resistance patterns 1

Special Considerations

Diagnosis

• Use Centor criteria to assess likelihood of Group A Streptococcal infection:

  • Fever by history
  • Tonsillar exudates
  • Tender anterior cervical adenopathy
  • Absence of cough 1, 4

• Patients with 0-2 Centor criteria are unlikely to have GAS infection

• Those with 3-4 criteria should be tested with rapid antigen detection test (RADT) and/or throat culture 1, 4

Symptom Management

• Patients are considered non-contagious after 24 hours of appropriate antibiotic therapy 1
• For symptom relief:
  • NSAIDs (first-line for pain management)
  • Acetaminophen
  • Warm salt water gargles
  • Throat lozenges 1

Treatment Failure

• For recurrent infections or chronic carriers:
  • Consider alternative regimens including clindamycin or combination therapy with rifampin 1
  • Decolonization strategies with intranasal mupirocin and chlorhexidine body washes may be considered 1

Tonsillectomy

• Consider for recurrent tonsillitis based on Paradise criteria:
  • ≥7 well-documented, adequately treated episodes in the preceding year, OR
  • ≥5 such episodes in each of the preceding 2 years, OR
  • ≥3 such episodes in each of the preceding 3 years 1, 4

Pitfalls to Avoid

• Inadequate treatment duration: Failure to complete the full 10-day course of antibiotics may lead to treatment failure and risk of rheumatic fever 1
• Overuse of macrolides: Significant resistance to azithromycin and clarithromycin exists in some parts of the US 4
• Unnecessary antibiotic use: Clinical features such as cough, rhinorrhea, hoarseness, and oral ulcers suggest a viral etiology, and testing for GAS pharyngitis is not recommended in such cases 1
• Treating carriers: Chronic GABHS carriers are at low risk of transmitting disease or developing invasive infections, and generally do not require treatment 5

While some studies have reported increased treatment failure rates with penicillin over time 6, current guidelines still strongly support penicillin or amoxicillin as first-line therapy due to their proven efficacy, narrow spectrum, and low cost 1, 4.