What is the recommended treatment for strep throat?

Strep Throat Treatment

The first-line treatment for strep throat is penicillin V (250 mg 4 times daily or 500 mg twice daily for 10 days in adults; 250 mg 2-3 times daily for 10 days in children) or amoxicillin (50 mg/kg once daily or 25 mg/kg twice daily for 10 days). 1

Diagnosis Before Treatment

Before initiating treatment, proper diagnosis is essential:

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

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

2. Testing:

   • Patients with 3-4 Centor criteria should receive a Rapid Antigen Detection Test (RADT) and/or throat culture
   • Patients with 0-2 criteria likely don't have GAS and don't require testing 1
   • RADT has high specificity but lower sensitivity than culture
   • Negative RADT should be confirmed with throat culture, especially in children 1

First-Line Treatment Options

For Non-Allergic Patients:

1. Penicillin V:

   • Adults: 250 mg 4 times daily or 500 mg twice daily for 10 days
   • Children: 250 mg 2-3 times daily for 10 days 1

2. Amoxicillin:

   • 50 mg/kg once daily (max 1000 mg) or 25 mg/kg twice daily (max 500 mg per dose) for 10 days 1, 2
   • Equally effective as penicillin and offers the advantage of once-daily dosing 3

Important: Treatment should continue for a minimum of 10 days to prevent acute rheumatic fever, regardless of symptom resolution 1, 2

For Penicillin-Allergic Patients:

• Non-anaphylactic allergy: First-generation cephalosporins (e.g., Cephalexin, Cefadroxil)
• Anaphylactic allergy: Clindamycin, Azithromycin, or Clarithromycin 1

Management of Treatment Failure

If symptoms persist after 48-72 hours of antibiotic therapy:

1. Reassess diagnosis to confirm strep throat

2. Consider causes:

   • Non-compliance with prescribed regimen
   • Streptococcal carrier with concurrent viral infection
   • New infection with GAS
   • True treatment failure (rare) 1

3. Change antibiotic:

   • Switch to amoxicillin-clavulanate (addresses potential beta-lactamase producing organisms)
   • Alternative: Clindamycin (20-30 mg/kg/day in 3 divided doses for children; 600 mg/day in 2-4 divided doses for adults)
   • For adults: Consider respiratory fluoroquinolones (levofloxacin or moxifloxacin) 1

Management of Recurrent Episodes

• For multiple recurrent episodes, consider clindamycin or amoxicillin-clavulanate for eradication 1
• Tonsillectomy may be considered for severe recurrent episodes (≥7 episodes in the past year, ≥5 episodes per year for 2 consecutive years, or ≥3 episodes per year for 3 consecutive years) 1, 4

Symptomatic Relief

While antibiotics address the infection, symptomatic relief is important:

• Throat sprays and lozenges (used every two hours)
• Cold liquids or ice chips
• Gargling with cold water
• NSAIDs for fever and pain (more effective than acetaminophen) 1

Important Considerations

• Duration: Complete the full 10-day course even if symptoms resolve earlier 1, 2
• Monitoring: Expect clinical improvement within 48-72 hours of starting antibiotics 1
• Compliance: Once-daily amoxicillin may improve compliance compared to multiple daily doses of penicillin 5, 3
• Resistance: There is significant resistance to azithromycin and clarithromycin in some parts of the US, so these should not be first-line choices 4

Caution: Recent studies show penicillin failure rates have increased to approximately 30% compared to 2-10% in earlier decades, possibly due to compliance issues, copathogenicity, or penicillin tolerance 6. Amoxicillin at 40 mg/kg/day has shown superior clinical and bacteriologic cure rates compared to lower-dose penicillin V 7.