What is the recommended antibiotic treatment for strep throat?

Recommended Antibiotic Treatment for Strep Throat

Amoxicillin 500 mg twice daily for 10 days is the first-line antibiotic treatment for strep throat (Group A Streptococcal pharyngitis), as recommended by the American College of Physicians and the Infectious Diseases Society of America. 1

First-Line Treatment Options

Penicillin-Based Antibiotics (Preferred)

• Amoxicillin:

  • Adults: 500 mg twice daily for 10 days
  • Children: 50 mg/kg once daily (max 1000 mg) or 25 mg/kg twice daily (max 500 mg per dose) for 10 days 1

• Penicillin V:

  • Adults: 500 mg twice daily for 10 days
  • Children: 250 mg 2-3 times daily for 10 days 1

• Benzathine Penicillin G (intramuscular):

  • Single dose of 1,200,000 U for adults ≥27 kg
  • Particularly useful for patients with anticipated compliance issues 1

Alternative Options for Penicillin-Allergic Patients

For Non-Anaphylactic Penicillin Allergy

• Cephalexin: 20 mg/kg twice daily (max 500 mg per dose) for 10 days 1

For Severe Penicillin Allergy (anaphylaxis, angioedema, respiratory distress)

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

Important Clinical Considerations

Diagnosis

Use the Centor Criteria to assess likelihood of Group A Streptococcal infection:

1. Tonsillar exudates
2. Tender anterior cervical lymph nodes
3. Lack of cough
4. Fever

• Patients with 0-2 criteria: unlikely to have GAS infection, no testing or antibiotics needed
• Patients with 3-4 criteria: test with rapid antigen detection test (RADT) and/or throat culture 1

Treatment Duration

• Complete the full course of antibiotics (10 days for all options except azithromycin, which is 5 days)
• The full 10-day course for beta-lactams is critical to:
  • Prevent acute rheumatic fever
  • Ensure complete bacterial eradication
  • Reduce risk of treatment failure 1

Common Pitfalls to Avoid

1. Inappropriate antibiotic use: Antibiotics should not be used for likely viral pharyngitis (those with cough, rhinorrhea, hoarseness, oral ulcers) 1

2. Incomplete treatment course: Failure to complete the full 10-day course increases risk of complications and treatment failure 1

3. Penicillin treatment failures: While penicillin has historically been the standard treatment, failure rates have increased over time (up to approximately 30%) 3. Amoxicillin is now often preferred due to better palatability with equal effectiveness 4

4. Macrolide resistance: Some studies have reported azithromycin resistance in approximately 1% of S. pyogenes isolates following therapy 2

Symptomatic Treatment

• NSAIDs or acetaminophen for pain and fever
• Warm salt water gargles
• Throat lozenges
• Reassure patients that symptoms typically resolve within one week 1

Special Considerations

• For patients with recurrent tonsillitis, consider tonsillectomy based on Paradise criteria (≥7 episodes in the preceding year, OR ≥5 episodes in each of the preceding 2 years, OR ≥3 episodes in each of the preceding 3 years) 1

• Household contacts of patients with Group A streptococcal pharyngitis do not routinely require throat cultures or treatment, except in specific high-risk situations 1