What is the recommended treatment for strep throat?

Strep Throat Treatment

For confirmed Group A Streptococcal (GAS) pharyngitis, the recommended first-line treatment is penicillin or amoxicillin for 10 days to prevent complications such as acute rheumatic fever. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• 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)
  • If RADT negative in children/adolescents, follow up with throat culture 1

Antibiotic Treatment Algorithm

First-line Treatment

• Amoxicillin:

  • Adults (≥40 kg): 500 mg twice daily OR 250 mg three times daily for 10 days
  • Children (<40 kg): 50 mg/kg once daily (max 1000 mg) OR 25 mg/kg twice daily (max 500 mg per dose) for 10 days 1, 2

• Penicillin V:

  • Adults: 250 mg three times daily for 10 days
  • 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
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 1

Important Treatment Considerations

1. Duration: 10-day course is essential for GAS pharyngitis to prevent acute rheumatic fever, even if symptoms improve earlier 1, 2

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

3. Dosing frequency: Twice-daily amoxicillin is as effective as more frequent dosing regimens, which may improve compliance 3

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

Symptomatic Relief

While antibiotics address the infection, symptom management is important:

• Analgesics/antipyretics (acetaminophen or NSAIDs) for pain and fever
• Avoid aspirin in children due to risk of Reye syndrome
• Warm salt water gargles, cold liquids, or ice chips for temporary relief
• Maintain adequate hydration 1

Follow-up and Special Considerations

• Evaluate for treatment failure if symptoms worsen or don't improve after 48-72 hours of antibiotic therapy
• Follow-up throat cultures are not routinely indicated for asymptomatic patients who have completed appropriate therapy
• For recurrent episodes, determine if the patient is experiencing multiple true GAS infections or is a chronic carrier with viral infections 1

Caution and Pitfalls

1. Antibiotic resistance: While penicillin resistance in GAS is not a significant concern, compliance with the full 10-day course is crucial to prevent treatment failure 4

2. Overtreatment: Only 10% of adults seeking care for sore throat have GAS pharyngitis, yet over 60% receive antibiotics; use clinical decision rules and testing to guide treatment 5

3. Compliance challenges: The 10-day duration can lead to poor adherence; ensure patients understand the importance of completing the full course even after symptoms resolve 4