What is the recommended treatment for strep throat in pediatrics (children)?

Treatment of Strep Throat in Pediatric Patients

Penicillin or amoxicillin is the first-line treatment for strep throat in children, administered for a standard 10-day course to ensure eradication and prevent complications. 1

First-Line Treatment Options

• Amoxicillin: Preferred first-line agent

  • Dosage: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose)
  • Duration: 10 days
  • Advantages: Narrow spectrum, proven efficacy, excellent safety profile, low cost, and better taste than penicillin (improving compliance) 1, 2
  • Administration: Should be taken at the start of a meal to minimize gastrointestinal intolerance 2

• Penicillin V: Alternative first-line agent

  • Recommended by both the American Academy of Pediatrics and Infectious Diseases Society of America 1
  • Duration: 10 days (full course required to prevent rheumatic fever)

Alternative Treatments for Penicillin-Allergic Patients

For children with penicillin allergy, the following options are recommended:

1. First-generation cephalosporins (e.g., cephalexin)

   • Preferred alternative due to lower relapse rates compared to macrolides
   • Note: May still cause reactions in patients with severe penicillin allergy

2. Clindamycin

   • Dosage: 20-30 mg/kg/day in divided doses
   • Duration: 10 days
   • Particularly useful for patients with multiple recurrent episodes 1

3. Azithromycin

   • Dosage: 12 mg/kg once daily (maximum 500 mg)
   • Duration: 5 days
   • Note: Higher rates of treatment failure may occur due to increasing macrolide resistance 1, 3

Management of Treatment Failure

If a child fails initial therapy, consider the following algorithm:

1. Assess compliance with the prescribed regimen

   • Poor compliance is a common cause of treatment failure 4

2. Evaluate for streptococcal carrier state with concurrent viral infection

3. For true treatment failure:

   • If failed amoxicillin, switch to amoxicillin-clavulanate
   • Consider clindamycin for continued treatment failure 1

Return to School Guidelines

• Children may return to school after completing 24 hours of appropriate antibiotic therapy, provided they are feeling well enough and fever has resolved 1, 5
• Recent research suggests that children treated with amoxicillin by 5 PM may be able to attend school the next morning if afebrile and improved, as 91% of children had negative cultures by the next morning 6
• However, the American Academy of Pediatrics still recommends completing a full 24 hours of antibiotics before returning to school 5

Diagnostic Considerations

• Use the Centor Criteria to assess likelihood of GAS pharyngitis:
  • Tonsillar exudates
  • Tender anterior cervical lymph nodes
  • Lack of cough
  • Fever
• Testing is recommended for patients with 3-4 criteria using rapid antigen detection tests (RADT) and/or throat culture 1
• Testing is generally not indicated for children under 3 years of age 1

Important Clinical Pearls

• Treatment duration: The full 10-day course of antibiotics is critical to prevent complications like rheumatic fever, even if symptoms resolve earlier 1
• Dosing frequency: Twice-daily dosing of penicillin V (500 mg BID) is as effective as four-times-daily dosing and improves compliance 7
• Symptomatic relief: Provide acetaminophen or NSAIDs for pain and fever (avoid aspirin in children due to risk of Reye syndrome) 1
• Hydration: Encourage adequate fluid intake during illness 1

By following these evidence-based recommendations, clinicians can effectively treat strep throat in pediatric patients while minimizing complications and preventing spread of infection.