What is the recommended treatment for a 9-year-old child diagnosed with streptococcal (strep) pharyngitis?

Treatment of Streptococcal Pharyngitis in a 9-Year-Old Child

The recommended first-line treatment for streptococcal pharyngitis in a 9-year-old child is oral penicillin V (250 mg 2-3 times daily) or amoxicillin (50 mg/kg once daily, maximum 1000 mg) for a full 10-day course. 1, 2

First-Line Treatment Options

Oral Antibiotics

• Penicillin V: 250 mg 2-3 times daily for 10 days 1, 2
• 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
  • Amoxicillin is often preferred for children due to better taste and once-daily dosing option

Injectable Option

• Benzathine penicillin G (intramuscular): For children <27 kg: 600,000 units; ≥27 kg: 1,200,000 units as a single dose 1
  • Consider this option when oral medication adherence is a concern

Alternative Options for Penicillin-Allergic Patients

For children with penicillin allergy, the following alternatives are recommended:

Non-Anaphylactic Penicillin Allergy

• Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1

Anaphylactic Penicillin Allergy or Cephalosporin Contraindication

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 2, 3
• Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1

Important Clinical Considerations

Treatment Duration

• Complete the full 10-day course of antibiotics (except for azithromycin which is 5 days) to:
  • Prevent acute rheumatic fever
  • Ensure complete eradication of Group A Streptococcus
  • Reduce risk of treatment failure 1, 2

Macrolide Resistance Warning

• Be aware that resistance of Group A Streptococcus to macrolides (azithromycin, clarithromycin) varies geographically and temporally 1
• Consider local resistance patterns when prescribing these alternatives

Treatment Goals

Treatment aims to:

• Prevent acute rheumatic fever
• Prevent suppurative complications (peritonsillar abscess, cervical lymphadenitis)
• Improve clinical symptoms
• Decrease contagiousness
• Reduce transmission to family members and classmates 1

Adjunctive Symptomatic Treatment

• NSAIDs or acetaminophen for pain and fever
• Warm salt water gargles
• Throat lozenges (for older children who can safely use them) 2

Follow-up Recommendations

• Seek medical attention if symptoms persist or worsen after 48-72 hours of antibiotic therapy 2
• Routine post-treatment throat cultures are not necessary if the patient is asymptomatic

Common Pitfalls to Avoid

1. Incomplete treatment course: Emphasize to parents the importance of completing the full 10-day course even if symptoms resolve earlier
2. Inappropriate macrolide use: Reserve macrolides for true penicillin-allergic patients due to increasing resistance concerns
3. Tonsillectomy solely for recurrent streptococcal pharyngitis: Not recommended as a first-line approach 1
4. Failure to test before treating: Ensure proper diagnosis with rapid antigen detection test or throat culture before initiating antibiotics 2, 4

By following these evidence-based recommendations, streptococcal pharyngitis can be effectively treated while minimizing complications and antibiotic resistance.