What is the recommended treatment for strep throat?

Strep Throat Treatment

The recommended first-line treatment for confirmed Group A Streptococcal (GAS) pharyngitis is penicillin V or amoxicillin for 10 days, with alternative options for patients with penicillin allergy including first-generation cephalosporins or clindamycin. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

1. Clinical Assessment: Use the Centor Criteria to evaluate likelihood of streptococcal pharyngitis:

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

2. Testing Approach:

   • Scores 0-1: Likely viral cause, no testing needed
   • Scores 2-3: Consider Rapid Antigen Detection Test (RADT)
   • Score of 4: High likelihood of GAS infection, consider empiric treatment or testing 1

3. Confirmation: Patients with 3-4 Centor criteria should be tested with RADT and/or throat culture to confirm the diagnosis 1

Treatment Algorithm

First-Line Treatment

• Penicillin V or Amoxicillin 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) 1, 3
  • Complete the full 10-day course to prevent complications such as acute rheumatic fever 1

Alternative Regimens (for Penicillin Allergy)

• First-generation cephalosporins (for non-anaphylactic penicillin allergy) 1, 2
• Clindamycin: 300-450 mg orally three times daily for 10 days 1
• Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 1

Important Clinical Considerations

1. Duration of Treatment:

   • Treatment should continue for a minimum of 48 to 72 hours beyond symptom resolution 3
   • A full 10-day course is crucial to prevent acute rheumatic fever (except for azithromycin which is 5 days) 1, 2

2. Efficacy Considerations:

   • Amoxicillin has shown higher clinical and bacteriologic cure rates compared to lower dosages of penicillin V in some studies 4
   • Twice-daily dosing of penicillin is as effective as more frequent dosing regimens, which may improve compliance 5
   • Once-daily penicillin is associated with decreased efficacy and should not be used 5

3. Antibiotic Resistance:

   • Significant resistance to azithromycin and clarithromycin exists in some parts of the United States 2
   • Clarithromycin is not recommended in areas with high clarithromycin resistance 6

Symptomatic Relief

In addition to antibiotics, symptomatic relief measures include:

• Cold liquids or ice chips
• Gargling with cold water
• Medicated throat lozenges every two hours
• NSAIDs for fever and pain (more effective than acetaminophen)
• Avoiding hot liquids and spicy foods 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

Patients should be reevaluated if:

• Symptoms worsen after appropriate antibiotic initiation
• Symptoms persist 5 days after starting treatment 2

Potential Pitfalls

1. Overtreatment: While 60% or more of adults with sore throat are prescribed antibiotics, only about 10% actually have GAS pharyngitis 2

2. Inadequate Duration: Failure to complete the full 10-day course increases the risk of complications, particularly acute rheumatic fever 1

3. Inappropriate Antibiotic Selection: Using macrolides in areas with high resistance can lead to treatment failure 2, 6

4. Unnecessary Tonsillectomy: Routine tonsillectomy is not recommended solely to reduce GAS pharyngitis frequency 1