What is the recommended management for strep throat?

Management of Strep Throat

Penicillin V or amoxicillin for a full 10-day course is the first-line treatment for streptococcal pharyngitis, with strong evidence supporting this approach to prevent rheumatic fever and ensure complete bacterial eradication. 1

Diagnosis and Evaluation

• Use the Centor Criteria to assess likelihood of Group A Streptococcal (GAS) infection:

  • Fever
  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough 1

• Testing recommendations:

  • 0-2 Centor criteria: No testing needed (unlikely GAS)
  • 3-4 Centor criteria: Test with rapid antigen detection test (RADT) and/or throat culture
  • Avoid testing when viral symptoms predominate (cough, rhinorrhea, hoarseness, oral ulcers) 1

• Confirmatory testing:

  • Children: Negative RADT results should be confirmed with throat culture
  • Adults: Negative RADT without culture confirmation is acceptable 1

Treatment Algorithm

First-line Treatment

• Penicillin V:

  • Children: 250 mg 2-3 times daily
  • Adolescents/adults: 500 mg 2-3 times daily
  • Duration: 10 days 1

• Amoxicillin:

  • 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose)
  • Duration: 10 days 1

For Penicillin-Allergic Patients

• Non-anaphylactic allergy:

  • First-generation cephalosporins (e.g., Cephalexin: 20 mg/kg twice daily, maximum 500 mg per dose) for 10 days 1, 2

• Anaphylactic allergy:

  • Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1
  • Macrolides (only if necessary due to increasing resistance):
    • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 3
    • Erythromycin (alternative for penicillin-allergic patients) 4

Important Considerations

• Complete the full antibiotic course: Completing the full 10-day course (except 5 days for azithromycin) is essential to:

  • Prevent treatment failure
  • Reduce risk of rheumatic fever
  • Prevent bacterial resistance 1

• Symptomatic treatment:

  • NSAIDs or acetaminophen
  • Warm salt water gargles
  • Throat lozenges 1

• Macrolide resistance caution:

  • Reserve macrolides like azithromycin for penicillin-allergic patients due to increasing resistance patterns 1, 5
  • Azithromycin may cause more adverse events (primarily gastrointestinal) than amoxicillin 5

• Follow-up recommendations:

  • Seek medical attention if symptoms persist or worsen after 48-72 hours of antibiotic therapy 1
  • No routine post-treatment testing is needed if symptoms resolve

Special Situations

• Recurrent infections: Consider alternative regimens including clindamycin or combination therapy with rifampin for recurrent infections or chronic carriers 1

• Tonsillectomy consideration: Based on Paradise criteria (≥7 episodes in 1 year, OR ≥5 episodes in each of 2 years, OR ≥3 episodes in each of 3 years) 1, 2

• Penicillin as drug of choice: Despite some studies showing potentially better symptom resolution with other antibiotics, penicillin remains the first-line treatment due to its proven efficacy in preventing rheumatic fever, narrow spectrum, low cost, and minimal resistance 1, 5

Common Pitfalls to Avoid

• Treating viral pharyngitis with antibiotics: Most sore throats are viral and do not require antibiotics 1

• Incomplete antibiotic course: Failure to complete the full 10-day course increases risk of treatment failure and rheumatic fever 1

• Using macrolides as first-line: Due to increasing resistance, macrolides should be reserved for penicillin-allergic patients 1, 5

• Neglecting local resistance patterns: Consider local resistance patterns when selecting antibiotics 1