What is the recommended treatment for strep throat?

Treatment of Strep Throat

Penicillin V or amoxicillin for 10 days is the recommended first-line treatment for strep throat, with amoxicillin being particularly effective and convenient for pediatric patients. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

1. Use Centor Criteria to assess likelihood of Group A Streptococcal (GAS) pharyngitis:

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

2. Testing recommendations:

   • Patients with 3-4 Centor criteria: Perform Rapid Antigen Detection Test (RADT) and/or throat culture
   • Patients with 0-2 criteria: Testing not required (unlikely to have GAS) 1
   • Negative RADT should be confirmed with throat culture in children and adolescents 1

Treatment Algorithm

First-Line Therapy

• Penicillin V: The traditional drug of choice due to narrow spectrum, proven efficacy, no documented resistance, and cost-effectiveness 1
• Amoxicillin: Equally effective and may have better compliance due to more convenient dosing 1, 2

Dosing Regimens

1. Adults and children ≥40 kg:

   • Penicillin V: 500 mg every 12 hours or 250 mg every 8 hours for 10 days
   • Amoxicillin: 500 mg every 12 hours or 875 mg every 12 hours for 10 days 1, 2

2. Children <40 kg:

   • Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2
   • For children <12 weeks: 30 mg/kg/day divided every 12 hours 2

Alternative Regimens (for penicillin-allergic patients)

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

Important: Complete the full 10-day course of antibiotics (except for azithromycin which is 5 days) to prevent complications such as acute rheumatic fever 1

Evidence Quality and Considerations

Recent evidence suggests amoxicillin may be more effective than penicillin for strep throat. A comparative study showed higher clinical cure rates (87.9% vs 70.9%) and bacteriologic cure rates (79.3% vs 54.5%) with amoxicillin compared to penicillin 3. This may be due to better compliance with amoxicillin's more convenient dosing schedule.

Regarding dosing frequency, twice-daily dosing of penicillin appears as effective as more frequent dosing regimens 4. Once-daily amoxicillin (750 mg) has also shown comparable efficacy to penicillin V given three times daily, which may further improve compliance 5.

Supportive Care

In addition to antibiotics, symptomatic relief is important:

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

Important Considerations

Contagious Period

• Patients remain contagious until they have been on appropriate antibiotics for at least 24 hours
• 96% of individuals become culture-negative within 24 hours of starting treatment 1
• Healthcare workers should stay away from clinical work until at least 24 hours of appropriate therapy and resolution of symptoms 1

Treatment Failure

If symptoms worsen after starting antibiotics or persist for 5 days after treatment initiation, patients should be reevaluated 6. Potential causes of treatment failure include:

• Poor compliance with the 10-day regimen
• Reexposure to infected individuals
• Copathogenicity with other bacteria
• Penicillin tolerance 7

When to Consider Tonsillectomy

Tonsillectomy is not routinely recommended solely to reduce GAS pharyngitis frequency but may be considered for patients with:

• ≥7 episodes of throat infection in the past year, OR
• ≥5 episodes per year for 2 consecutive years, OR
• ≥3 episodes per year for 3 consecutive years 1, 6

Prevention of Complications

• Proper identification and adequate antibiotic treatment of GAS pharyngitis is crucial for preventing acute rheumatic fever
• Continuous antimicrobial prophylaxis is recommended for patients with a history of rheumatic fever 1