What is the recommended treatment for strep throat?

Strep Throat Treatment

Penicillin or amoxicillin is the recommended first-line treatment for Group A Streptococcal (GAS) pharyngitis due to their narrow spectrum of activity, infrequency of adverse reactions, and modest cost. 1, 2

First-Line Treatment Options

For Non-Penicillin Allergic Patients:

1. Oral Options:

   • Penicillin V:

     • Children: 250 mg twice or three times daily
     • Adolescents/adults: 250 mg four times daily or 500 mg twice daily
     • Duration: 10 days 1

   • Amoxicillin:

     • 50 mg/kg once daily (maximum 1000 mg)
     • Alternative: 25 mg/kg twice daily (maximum 500 mg per dose)
     • Duration: 10 days 1, 3

2. Injectable Option:

   • Benzathine penicillin G (intramuscular):
     • <27 kg: 600,000 U
     • ≥27 kg: 1,200,000 U
     • Single dose 1

For Penicillin-Allergic Patients:

• First choice: Clindamycin 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days 1, 2
• Alternatives:
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days
  • Clarithromycin: 7.5 mg/kg/dose twice daily (max 250 mg/dose) for 10 days 1

Important: GAS resistance to macrolides (azithromycin, clarithromycin) varies geographically and temporally 1

Treatment Duration

A full 10-day course of antibiotics is essential for:

• Complete eradication of the organism from the pharynx
• Prevention of acute rheumatic fever
• Reduction of symptoms 1, 2

The only exception is azithromycin, which is given for 5 days due to its prolonged tissue persistence 1.

When to Test for Strep Throat

Testing for GAS pharyngitis is not recommended when:

• Clinical features strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers) 1, 2
• Children are under 3 years old (unless they have specific risk factors like an older sibling with GAS infection) 1

Follow-Up Recommendations

• Routine post-treatment throat cultures or rapid antigen detection tests are not recommended 1
• Patients should remain isolated for at least 24 hours after starting effective antibiotic therapy 2, 4

Clinical Pearls

• Early treatment of streptococcal pharyngitis can reduce symptom duration to less than 24 hours in most cases 5
• While once-daily amoxicillin (750 mg) has shown similar efficacy to penicillin V given three times daily in some studies, the standard recommendation remains multiple daily doses 6
• Although penicillin has been the gold standard for decades, some studies report increasing bacteriologic failure rates (up to 30%) 7
• Symptomatic relief with analgesics like ibuprofen or acetaminophen is important alongside antibiotic therapy 2
• Avoid aspirin in children due to the risk of Reye syndrome 2

Treatment Algorithm

1. Assess likelihood of GAS pharyngitis using Centor Criteria
2. Test only if clinical features suggest bacterial infection
3. If positive:
   • No penicillin allergy: Prescribe penicillin V or amoxicillin for 10 days
   • Penicillin allergy: Prescribe clindamycin for 10 days or a macrolide
4. Advise patient to complete the full course of antibiotics even if symptoms improve
5. Recommend returning to school/work only after 24 hours of antibiotic therapy

Remember that the primary goal of treatment is to prevent acute rheumatic fever, reduce symptoms, and prevent transmission to others.