What is the recommended treatment for strep throat in children?

Treatment of Strep Throat in Children

Penicillin or amoxicillin is the first-line treatment for strep throat in children, administered for a full 10-day course to prevent acute rheumatic fever and other complications. 1, 2

First-Line Treatment Options

Penicillin/Amoxicillin (First Choice)

• Penicillin V: 250 mg 2-3 times daily for children (10 days)
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 2
  • Amoxicillin is often preferred for children due to better taste and once/twice daily dosing
  • Both medications have narrow spectrum of activity, infrequent adverse reactions, modest cost, and proven efficacy 1

For Penicillin-Allergic Patients

Non-Anaphylactic Penicillin Allergy

• First-generation cephalosporins (10 days): 1
  • Cephalexin: 20 mg/kg/dose twice daily (maximum 500 mg/dose)
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g)

Anaphylactic Penicillin Allergy

• Clindamycin: 7 mg/kg/dose three times daily (maximum 300 mg/dose) for 10 days 1, 2
• Clarithromycin: 7.5 mg/kg/dose twice daily (maximum 250 mg/dose) for 10 days 1, 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 2, 3
  • Note: Azithromycin resistance is increasing in some areas 2

Diagnosis Before Treatment

• Clinical features alone cannot reliably differentiate Group A Streptococcal (GAS) from viral pharyngitis
• Laboratory confirmation is necessary through:
  • Rapid Antigen Detection Test (RADT)
  • Throat culture if RADT is negative (particularly important in children) 2
• Testing generally not recommended in children <3 years old unless specific risk factors exist 1

Adjunctive Therapy

• Analgesics/antipyretics for symptom relief:
  • Acetaminophen or ibuprofen for pain and fever 1, 2
  • Avoid aspirin in children due to risk of Reye syndrome 1
• Supportive measures:
  • Cold liquids or ice chips
  • Warm salt water gargles
  • Throat lozenges (for older children) 2

Important Considerations

1. Duration of therapy: A full 10-day course is mandatory to prevent acute rheumatic fever (except for azithromycin which is 5 days) 2

2. Return to school: Children should complete at least 24 hours of antibiotics before returning to school to reduce transmission risk 2, 4

3. Treatment failures: If symptoms persist after 48-72 hours of therapy, reevaluation is necessary 2

   • Penicillin treatment failures occur in approximately 30% of cases 5
   • For treatment failures, consider clindamycin, amoxicillin-clavulanate, or cephalosporins 2

4. Follow-up: Routine post-treatment cultures are not indicated unless symptoms persist 1, 2

5. Recurrent infections: Tonsillectomy may be considered for patients with frequent recurrences (7+ episodes in 1 year, 5+ episodes in each of 2 consecutive years, or 3+ episodes in each of 3 consecutive years) 6

Caution

• Despite some studies suggesting shorter courses of certain antibiotics, the standard 10-day course of penicillin/amoxicillin remains recommended to prevent acute rheumatic fever 2
• Macrolide resistance (affecting azithromycin and clarithromycin) is increasing in some regions 2
• Adjunctive therapy with corticosteroids is not recommended 1