What is the recommended treatment for recurrent streptococcal (strep) pharyngitis in a patient with an allergy to amoxicillin?

Treatment for Recurrent Streptococcal Pharyngitis in Patients with Amoxicillin Allergy

For patients with recurrent streptococcal pharyngitis who have an allergy to amoxicillin, first-generation cephalosporins (if not anaphylactically sensitive to penicillin), clindamycin, clarithromycin, or azithromycin are the recommended treatment options. 1

First-Line Treatment Options for Penicillin-Allergic Patients

For patients without anaphylactic sensitivity to penicillin:

• First-generation cephalosporins for 10 days:
  • Cephalexin (Keflex): 20 mg/kg per dose twice daily (maximum = 500 mg per dose) 1
  • Cefadroxil: 30 mg/kg once daily (maximum = 1 g) 1

For patients with anaphylactic sensitivity to penicillin:

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

Considerations for Recurrent Streptococcal Pharyngitis

When managing recurrent streptococcal pharyngitis, clinicians should consider:

• Whether the patient is experiencing true recurrent infections or is a chronic carrier with viral infections 1, 3
• For confirmed recurrent infections, clindamycin has shown significantly better clinical cure rates at 12 days compared to amoxicillin/clavulanate in one study 4
• Resistance to macrolides (azithromycin and clarithromycin) varies geographically and should be considered when selecting treatment 1, 5

Diagnostic Approach for Recurrent Cases

• Confirm each episode with rapid antigen detection test (RADT) or throat culture 1
• A positive RADT is diagnostic and does not require backup culture 1
• For negative RADT in children and adolescents, a backup throat culture is recommended 1, 5
• Follow-up post-treatment cultures are not routinely recommended but may be considered in special circumstances 1, 3

Adjunctive Therapy

• Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever 1, 6
• Avoid aspirin in children due to risk of Reye syndrome 1, 3
• Corticosteroids are not recommended for routine use 1
• Medicated throat lozenges used every two hours may provide symptomatic relief 6

Common Pitfalls to Avoid

• Overdiagnosis and overtreatment of viral pharyngitis as bacterial infection 1, 5
• Failing to distinguish between true recurrent infections and chronic carriage with viral infections 1, 3
• Using macrolides in areas with high resistance rates 1, 5
• Unnecessary tonsillectomy solely to reduce frequency of GAS pharyngitis 1, 3

Special Considerations

• Chronic carriers generally do not require antimicrobial therapy as they are unlikely to spread GAS pharyngitis and are at low risk for complications 1, 7
• Tonsillectomy should only be considered in extreme cases with very frequent documented infections (e.g., seven episodes in one year or five episodes per year for two consecutive years) 5