What is the recommended treatment for strep throat?

Treatment for Strep Throat

Penicillin or amoxicillin is the first-line treatment for strep throat, with a full 10-day course required to prevent complications such as acute rheumatic fever. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Use Centor Criteria to assess likelihood of Group A Streptococcus (GAS) pharyngitis
• Rapid Antigen Detection Tests (RADTs) should be used for patients with high likelihood (3-4 Centor criteria)
• Clinical features alone are insufficient for diagnosis 1
• After a negative rapid antigen test, a throat culture is recommended for children and adolescents 2

First-Line Treatment Options

Penicillin V

• Adults: 250 mg four times daily or 500 mg twice daily for 10 days
• Children: 250 mg three times a day for 10 days (for <27 kg: 600,000 U; for ≥27 kg: 1,200,000 U) 1

Amoxicillin (Preferred for children due to better taste)

• Children: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days
• Adults: 500 mg every 12 hours or 250 mg every 8 hours for 10 days 1, 3

Alternative Treatments (for penicillin-allergic patients)

• Clindamycin: 300-450 mg orally three times daily for 10 days
• Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days
• Clarithromycin: Note that there is significant resistance to azithromycin and clarithromycin in some parts of the US 2

Important Treatment Considerations

• Treatment should be initiated within 9 days of symptom onset to prevent acute rheumatic fever 1
• A full 10-day course is essential for complete eradication (except for azithromycin: 5 days) 1
• Twice-daily dosing of penicillin is as effective as more frequent dosing, but once-daily dosing of penicillin is less effective 4
• Once-daily amoxicillin has shown comparable effectiveness to three-times-daily penicillin V 5
• Patients should take antibiotics at the start of a meal to minimize gastrointestinal intolerance 3

Special Populations

• For children under 3 years, presentation differs with fever, mucopurulent rhinitis, excoriated nares, and diffuse adenopathy 1
• Patients with severe renal impairment (GFR <30 mL/min) should not receive the 875 mg dose of amoxicillin 3
• For patients with GFR 10-30 mL/min: 500 mg or 250 mg every 12 hours
• For patients with GFR <10 mL/min: 500 mg or 250 mg every 24 hours 3

Follow-up and Complications

• Follow-up throat cultures are not routinely recommended except for patients with:
  • History of rheumatic fever
  • During outbreaks of acute rheumatic fever or post-streptococcal glomerulonephritis
  • During outbreaks in closed communities 1
• Patients should be reevaluated if symptoms worsen after starting antibiotics or if symptoms persist for 5 days after treatment initiation 2

Prevention Measures

• Maintain isolation precautions for at least 24 hours after starting effective antibiotic therapy 1
• Practice good hand hygiene and avoid sharing utensils or drinks 1
• Maintain hydration during recovery 1
• Testing or treatment of asymptomatic household contacts is not routinely recommended 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: A full 10-day course is necessary to prevent complications, even if symptoms resolve earlier
2. Inappropriate antibiotic selection: Using broad-spectrum antibiotics when narrow-spectrum options are effective
3. Treating viral pharyngitis: Only 10% of adults with sore throat have GAS pharyngitis, yet 60% or more receive antibiotics 2
4. Overlooking compliance issues: Poor compliance is a major cause of treatment failure 6
5. Failing to consider local resistance patterns: Some regions have high resistance to macrolides 7