What is the recommended treatment for strep throat in adults?

Treatment of Strep Throat in Adults

Penicillin or amoxicillin for 10 days is the recommended first-line treatment for strep throat (Group A Streptococcal pharyngitis) in adults. 1, 2

Diagnosis Before Treatment

Before initiating treatment, proper diagnosis is essential:

• Clinical features alone cannot reliably differentiate between GAS and viral pharyngitis

• Use Centor Criteria to guide testing decisions:

  • Tonsillar exudates
  • Tender anterior cervical lymph nodes
  • Lack of cough
  • Fever 1

• For adults with 3-4 Centor criteria, perform rapid antigen detection test (RADT)

• Unlike in children, negative RADTs in adults do not require backup throat culture due to lower incidence of GAS pharyngitis and minimal risk of acute rheumatic fever 2

First-Line Antibiotic Treatment

• Penicillin V: 500 mg 2-3 times daily for 10 days 1
• Amoxicillin: 500 mg twice daily or 1000 mg once daily for 10 days 1, 3
  • Amoxicillin is often preferred due to better taste and more convenient dosing schedule
  • Both medications have a narrow spectrum of activity, infrequent adverse reactions, and modest cost 2

Treatment for Penicillin-Allergic Patients

For patients with penicillin allergy, alternatives include:

• Non-anaphylactic allergy: First-generation cephalosporins for 10 days 2, 1
• Anaphylactic allergy:
  • Clindamycin: 300-450 mg three times daily for 10 days
  • Clarithromycin: 250 mg twice daily for 10 days
  • Azithromycin: 500 mg once daily for 5 days 2, 1

Important: Be aware that there is significant resistance to azithromycin and clarithromycin in some parts of the United States 4

Symptomatic Relief

Adjunctive therapy is important for patient comfort:

• Analgesics/antipyretics such as acetaminophen or NSAIDs for pain and fever relief 2, 1
• Throat lozenges and warm salt water gargles for symptomatic relief
• Cold liquids or ice chips can provide comfort
• Avoid hot liquids and spicy foods that may irritate the throat 1

Follow-Up and Treatment Failures

• Routine post-treatment cultures are not indicated unless symptoms persist 1
• If symptoms persist after 48-72 hours of antibiotic therapy, reevaluation is necessary 1
• Penicillin treatment failures occur in approximately 30% of cases 5
• For treatment failures, consider:
  • Clindamycin
  • Amoxicillin-clavulanate
  • Cephalosporins 1

Return to Work Considerations

Patients should complete at least 24 hours of antibiotics before returning to work to reduce transmission risk 1

Treatment Duration Considerations

A full 10-day course of antibiotics is mandatory to prevent acute rheumatic fever (with the exception of azithromycin, which has a 5-day course) 1. While some research has explored shorter courses of treatment such as 6-day amoxicillin regimens 6, the current guidelines still strongly recommend the full 10-day course for beta-lactam antibiotics to ensure complete eradication of the organism and prevention of complications 2, 1.