What is the treatment for strep throat?

Treatment for Strep Throat

Penicillin V is the first-line treatment for strep throat, administered as 250 mg four times daily or 500 mg twice daily for 10 days. 1

Diagnostic Approach

Before initiating treatment, proper diagnosis is essential:

1. Use the Centor Criteria to assess likelihood of Group A Streptococcus (GAS) pharyngitis:

   • Fever ≥38°C
   • Absence of cough
   • Tonsillar exudate
   • Anterior cervical lymphadenopathy

2. Perform Rapid Antigen Detection Test (RADT) in patients with high likelihood of streptococcal infection (3-4 Centor criteria) 1

3. Confirm diagnosis with throat culture, especially for negative RADT results in children and adolescents 2

Antibiotic Treatment Options

First-line Treatment

• Penicillin V: 250 mg four times daily or 500 mg twice daily for 10 days 1
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1

For Penicillin-Allergic Patients

• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1
• Clindamycin: 300-450 mg orally three times daily for 10 days 1

Important Treatment Considerations

• A full 10-day course of penicillin therapy is crucial to eliminate the organism and prevent sequelae of streptococcal disease, including acute rheumatic fever 3, 4
• Shortening the course of penicillin by even a few days results in increased treatment failure rates 3
• The oral route should not be relied upon in patients with severe illness, nausea, vomiting, gastric dilatation, cardiospasm, or intestinal hypermotility 4
• Patients should complete the full course of antibiotics even if they feel better early in treatment to prevent bacterial resistance 4

Common Pitfalls to Avoid

1. Inadequate treatment duration: Failure to complete the full 10-day course of penicillin can lead to treatment failure and risk of complications 3, 4

2. Overdiagnosis and overtreatment: Only 10% of adults seeking care for sore throat have GAS pharyngitis, yet 60% or more receive antibiotics 2

3. Inappropriate antibiotic selection: There is significant resistance to azithromycin and clarithromycin in some parts of the US 2

4. Premature return to school/daycare: Patients should complete a full 24 hours of antibiotics before returning to school or daycare to prevent transmission 5

5. Failure to recognize treatment failure: Patients with worsening symptoms after antibiotic initiation or symptoms lasting 5 days after starting treatment should be reevaluated 2

Follow-up

• Cultures should be taken following completion of treatment to determine whether streptococci have been eradicated, especially in high-risk cases 4
• Patients should be monitored for potential complications, including suppurative complications (quinsy, acute otitis media, cervical lymphadenitis) and non-suppurative complications (acute rheumatic fever, acute glomerulonephritis) 1

The 10-day course of penicillin or amoxicillin remains the gold standard for treating strep throat, with the primary goal being the prevention of acute rheumatic fever and other complications while achieving symptomatic improvement.