What is the recommended treatment for strep (streptococcal) pharyngitis?

Treatment of Streptococcal Pharyngitis

Penicillin or amoxicillin is the recommended first-line treatment for streptococcal pharyngitis due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1

First-Line Treatment Options

For Patients Without Penicillin Allergy:

• Oral Penicillin V (10-day course):

  • Children: 250 mg two or three times daily
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily 1

• Oral Amoxicillin (10-day course):

  • 50 mg/kg once daily (maximum = 1,000 mg)
  • Alternative: 25 mg/kg twice daily (maximum = 500 mg) 1
  • Amoxicillin is often preferred for young children due to better taste acceptance 1

• Intramuscular Benzathine Penicillin G (single dose):

  • < 60 lb (27 kg): 600,000 units
  • ≥ 60 lb: 1,200,000 units 1
  • Preferred for patients unlikely to complete a full 10-day oral course 1

For Patients With Penicillin Allergy:

• First-generation Cephalosporins (for non-anaphylactic allergy, 10-day course):

  • Cephalexin: 20 mg/kg per dose twice daily (maximum = 500 mg per dose)
  • Cefadroxil: 30 mg/kg once daily (maximum = 1 g) 1

• Clindamycin (10-day course):

  • 7 mg/kg per dose three times daily (maximum = 300 mg per dose) 1

• Macrolides (for anaphylactic penicillin allergy):

  • Clarithromycin: 7.5 mg/kg per dose twice daily for 10 days (maximum = 250 mg per dose)
  • Azithromycin: 12 mg/kg once daily for 5 days (maximum = 500 mg) 1

Diagnostic Considerations

• Testing is recommended for patients with clinical features suggesting streptococcal infection:

  • Sudden onset of sore throat, fever, headache
  • Tonsillopharyngeal inflammation or exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough, rhinorrhea, or hoarseness (which suggest viral etiology) 1

• A positive rapid antigen detection test (RADT) is diagnostic for group A streptococcal pharyngitis 1

• A backup throat culture should be performed in children and adolescents with negative RADT results 1

Adjunctive Therapy

• Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever 1
• Aspirin should be avoided in children due to risk of Reye syndrome 1
• Corticosteroids are not recommended as adjunctive therapy 1

Special Considerations

Treatment Duration

• The standard 10-day course of antibiotics is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1
• While some newer agents (azithromycin, certain cephalosporins) have been studied for shorter courses, the 10-day regimen remains the standard recommendation for penicillin and amoxicillin 1

Recurrent Infections

• Patients with recurrent pharyngitis may be experiencing true reinfections or may be chronic carriers experiencing viral infections 1
• For documented recurrent infections, consider:
  • Retreatment with the same agent used initially
  • Intramuscular benzathine penicillin G if compliance with oral therapy is questionable
  • Clindamycin or amoxicillin/clavulanate for chronic carriers 1

Common Pitfalls to Avoid

• Overtreatment: Avoid prescribing antibiotics for likely viral pharyngitis (with cough, rhinorrhea, hoarseness, oral ulcers) 1, 2
• Inappropriate testing: Testing is generally not recommended in children younger than 3 years unless they have risk factors such as an older sibling with GAS infection 1
• Macrolide resistance: Be aware that resistance to azithromycin and clarithromycin varies geographically and may be significant in some regions 1, 2
• Unnecessary follow-up testing: Routine post-treatment throat cultures are not recommended for asymptomatic patients 1
• Inadequate dosing: Ensure appropriate dosing of antibiotics, as inadequate dosing may contribute to treatment failures 3