What is the recommended treatment for strep throat?

Streptococcal Pharyngitis Treatment

Amoxicillin (50 mg/kg once daily or 25 mg/kg twice daily for 10 days) is the recommended first-line treatment for streptococcal pharyngitis, with penicillin V as an acceptable alternative. 1

First-Line Treatment Options

For Children:

• Amoxicillin oral:
  • 50 mg/kg once daily (maximum 1000 mg) OR
  • 25 mg/kg twice daily (maximum 500 mg per dose)
  • Duration: 10 days 1, 2

For Adults:

• Amoxicillin oral:
  • 500 mg every 12 hours OR
  • 250 mg every 8 hours
  • Duration: 10 days 1, 2
• Penicillin V oral:
  • 250 mg three times daily
  • Duration: 10 days 1

Alternative Treatment Options for Penicillin-Allergic Patients

Non-Anaphylactic Penicillin Allergy:

• Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1

Anaphylactic Penicillin Allergy:

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1
  • Caution: Significant resistance to macrolides exists in some regions of the US 1, 3

Important Clinical Considerations

Duration of Treatment

• Complete the full 10-day course of antibiotics even if symptoms improve earlier
• This is essential to prevent acute rheumatic fever, a serious complication 1

Diagnosis Before Treatment

• Antibiotics should only be prescribed when there is high likelihood of streptococcal infection:
  • Use Centor criteria (fever, tonsillar exudate, cervical lymphadenitis, absence of cough)
  • For patients with 3-4 Centor criteria, perform Rapid Antigen Detection Test (RADT)
  • For children with negative RADT, follow up with throat culture 1, 3

Symptomatic Treatment

• Acetaminophen for moderate to severe symptoms or fever control
• Avoid aspirin in children due to risk of Reye's syndrome
• Corticosteroids are not recommended as adjuvant therapy 1, 3

Treatment Efficacy Considerations

Amoxicillin has demonstrated superior efficacy compared to standard-dose penicillin:

• Higher clinical cure rates (87.9% vs 70.9%)
• Better bacteriologic cure rates (79.3% vs 54.5%) 4
• Once-daily dosing of amoxicillin (750 mg) has shown comparable efficacy to penicillin V given three times daily, potentially improving compliance 5

Follow-up Recommendations

• Routine post-treatment throat cultures are not recommended 1
• Patients should be reevaluated if:
  • Symptoms worsen after starting antibiotics
  • Symptoms persist for 5 days after treatment initiation 3

Prevention and Control

• Maintain isolation precautions for at least 24 hours after starting effective antibiotic therapy
• Healthcare workers with symptomatic infection should avoid work until 24 hours of appropriate treatment and symptom resolution 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Always complete the full 10-day course of antibiotics to prevent complications
2. Inappropriate macrolide use: Be aware of regional resistance patterns before prescribing azithromycin
3. Overtreatment: Avoid prescribing antibiotics for likely viral pharyngitis (patients with 0-2 Centor criteria)
4. Dosing errors: Ensure appropriate weight-based dosing in children
5. Failure to adjust for renal impairment: Patients with severe renal impairment (GFR <30 mL/min) require dosage adjustments 1, 2