What is the recommended treatment for streptococcal (strep) pharyngitis?

Treatment of Streptococcal Pharyngitis

For confirmed streptococcal pharyngitis, the first-line treatment is penicillin V or amoxicillin for 10 days, with alternatives such as first-generation cephalosporins or clindamycin for penicillin-allergic patients. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Use the Centor Criteria to assess likelihood of streptococcal pharyngitis:

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

• Testing recommendations:

  • Centor score 0-1: Likely viral, no testing needed
  • Centor score 2-3: Perform Rapid Antigen Detection Test (RADT)
  • Centor score 4: Consider empiric treatment or testing 1

Treatment Algorithm

First-line Treatment

• Penicillin V: 250 mg orally three times daily for 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 1

Alternative Treatments (for penicillin allergy)

• First-generation cephalosporins: For non-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 1, 2

Efficacy Considerations

• Azithromycin has shown clinical success rates of 95% in eradicating Group A β-hemolytic streptococci compared to 73% with penicillin V at day 14 2
• However, penicillin remains the first-line treatment due to:
  1. Lower risk of antimicrobial resistance
  2. Proven efficacy in preventing rheumatic fever
  3. Longer clinical experience 1

Important Treatment Principles

• Complete the full course of antibiotics (10 days for penicillin/amoxicillin, 5 days for azithromycin) to prevent complications like acute rheumatic fever 1
• Patients should complete at least 24 hours of antibiotics before returning to school or work to reduce transmission risk 1
• Benefits of antibiotics for confirmed GAS pharyngitis include:
  • Accelerated symptom relief
  • Reduced risk of suppurative complications
  • Prevention of acute rheumatic fever 1

Symptomatic Relief

While antibiotics address the infection, symptomatic relief is important:

• Cold liquids or ice chips
• Gargling with cold water
• NSAIDs (more effective than acetaminophen for fever and pain)
• Medicated throat lozenges every two hours
• Avoid hot liquids and spicy foods 1

Special Considerations

• Chronic carriers of GAS generally don't require treatment unless specific circumstances exist, such as family history of rheumatic fever or outbreaks 1
• Routine tonsillectomy is not recommended solely to reduce the frequency of GAS pharyngitis 1
• Consider tonsillectomy only for patients with recurrent infections (≥7 episodes in the past year, OR ≥5 episodes per year for 2 consecutive years, OR ≥3 episodes per year for 3 consecutive years) 1

Treatment Pitfalls to Avoid

• Incomplete treatment course: Failing to complete the full antibiotic course increases risk of rheumatic fever
• Inappropriate antibiotic selection: Using broad-spectrum antibiotics when not indicated
• Treating viral pharyngitis with antibiotics: Confirm streptococcal etiology before prescribing antibiotics
• Neglecting follow-up: For patients with high risk of rheumatic fever or complications