What is the recommended treatment for severe strep throat?

Treatment for Severe Strep Throat

The first-line treatment for severe strep throat is penicillin V or amoxicillin for a full 10-day course, with amoxicillin often preferred due to better taste and ease of administration. 1

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis using:

• Centor Criteria to assess likelihood of streptococcal infection:

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

• Testing: Rapid Antigen Detection Test (RADT) and/or throat culture for patients with 3-4 Centor criteria 1

First-Line Antibiotic Treatment

For confirmed Group A Streptococcal (GAS) pharyngitis:

• Penicillin V:

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

• Amoxicillin (often preferred due to better taste):

  • 50 mg/kg once daily (maximum 1000 mg) OR
  • 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1

Important: The full 10-day course must be completed even if symptoms improve before completion to prevent complications such as acute rheumatic fever 1, 2

Alternative Treatments for Penicillin-Allergic Patients

• Non-anaphylactic penicillin allergy:

  • First-generation cephalosporins for 10 days 1

• Anaphylactic penicillin allergy:

  • Clindamycin: 300-450 mg orally three times daily for 10 days
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days
  • Clarithromycin: for 10 days 1, 3

Caution: Significant resistance to azithromycin and clarithromycin exists in some parts of the United States 1, 4

Supportive Care

• Pain and fever management:

  • Acetaminophen or NSAIDs (avoid aspirin in children due to risk of Reye's syndrome) 1

• Hydration and comfort measures:

  • Cold liquids or ice chips
  • Gargling with cold water
  • Avoiding hot liquids and spicy/hard foods 1

Prevention of Complications

Completing the full antibiotic course is essential to prevent:

• Acute rheumatic fever
• Peritonsillar abscess
• Cervical lymphadenitis
• Transmission to close contacts 1

Return to School/Work

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

When to Reevaluate

Reevaluation is necessary if:

• Symptoms worsen after antibiotic initiation
• Symptoms persist for 5+ days after starting treatment 4

Treatment Failures

If treatment failure occurs with penicillin (which happens in approximately 30% of cases), consider:

• Patient non-compliance with the 10-day regimen
• Reexposure to infected individuals
• Penicillin tolerance 5

In such cases, cephalosporins may be more effective at eradicating GAS than penicillin 5, 6