What is the recommended treatment for strep throat?

Strep Throat Treatment

The first-line treatment for Group A Streptococcal (GAS) pharyngitis is penicillin or amoxicillin for 10 days, with amoxicillin being preferred due to better taste and improved compliance. 1

Diagnosis Before Treatment

• Use Centor Criteria to assess likelihood of GAS pharyngitis:
  • Tonsillar exudates
  • Tender anterior cervical lymph nodes
  • Lack of cough
  • Fever
• For patients with 3-4 Centor criteria, perform rapid antigen detection test (RADT) and/or throat culture 1
• A positive RADT is diagnostic; negative results in children and adolescents should be backed up with throat culture 1

Antibiotic Treatment Algorithm

First-line therapy:

• Amoxicillin:

  • Adults: 500 mg twice daily or 250 mg three times daily for 10 days 1, 2
  • Children <40 kg: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2
  • Children <12 weeks: 30 mg/kg/day divided every 12 hours (due to incompletely developed renal function) 2

• Penicillin V:

  • Adults: 250 mg three times daily or 500 mg twice daily for 10 days 1
  • Children: Weight-based dosing for 10 days 1

For penicillin-allergic patients:

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

Important Treatment Considerations

1. 10-day treatment duration is crucial: Treatment must continue for 10 days to prevent acute rheumatic fever, even if symptoms resolve earlier 1, 2

2. Timing: While early initiation results in faster symptom resolution, therapy can be safely postponed up to 9 days after symptom onset and still prevent acute rheumatic fever 1

3. Dosing frequency: Twice-daily dosing of penicillin is as effective as more frequent dosing regimens, but once-daily dosing of penicillin is associated with lower cure rates (avoid once-daily penicillin) 3

4. Return to school/work: Patients are considered non-contagious after 24 hours of effective antibiotic therapy 1

5. Symptomatic relief:

   • Acetaminophen or NSAIDs for pain/fever (avoid aspirin in children)
   • Warm salt water gargles, cold liquids, ice chips
   • Maintain hydration 1

Treatment Failures and Special Considerations

• Evaluate for treatment failure if symptoms worsen or don't improve after 48-72 hours of antibiotic therapy 1
• Bacteriologic failure rates with penicillin therapy have increased over time and are now reported to be approximately 30% 4
• Causes of treatment failure include:
  • Poor compliance with the 10-day regimen
  • Reexposure to infected individuals
  • Copathogenicity with other bacteria
  • Penicillin tolerance 4

Follow-up

• Follow-up throat cultures are not routinely indicated for asymptomatic patients who have completed appropriate therapy 1
• Consider tonsillectomy only in cases of recurrent streptococcal pharyngitis (7+ episodes in 1 year, 5+ episodes in each of 2 years, or 3+ episodes in each of 3 years) 5

Prevention

• Practice good hand hygiene
• Avoid sharing utensils, drinks, or food
• Cover mouth when coughing or sneezing 1