What is the recommended treatment for Streptococcal (Strep) pharyngitis?

Treatment of Streptococcal Pharyngitis

Penicillin or amoxicillin remains the treatment of choice for streptococcal pharyngitis due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1, 2

First-Line Treatment Options

• For patients without penicillin allergy, oral penicillin V for 10 days is recommended with a dosage of 250 mg two to three times daily for children and 250 mg four times daily or 500 mg twice daily for adolescents and adults 1, 2
• Amoxicillin is an equally effective alternative to penicillin V, particularly for young children due to better taste acceptance, and can be given as 50 mg/kg once daily (maximum = 1,000 mg) or 25 mg/kg twice daily (maximum = 500 mg) for 10 days 1, 2
• Intramuscular benzathine penicillin G as a single dose is preferred for patients who are unlikely to complete a full 10-day course of oral therapy, with a dosage of 600,000 units for patients < 60 lb (27 kg) and 1,200,000 units for patients ≥ 60 lb 1, 2

Treatment for Penicillin-Allergic Patients

• For patients with penicillin allergy, first-generation cephalosporins (e.g., cefadroxil or cephalexin) for 10 days are recommended for those without immediate hypersensitivity to β-lactam antibiotics 1
• Patients with immediate (anaphylactic-type) hypersensitivity to penicillin should receive either clindamycin (10 days), clarithromycin (10 days), or azithromycin (5 days) 1
• Macrolide resistance among Group A Streptococcus (GAS) isolates in the United States is around 5-8%, which should be considered when prescribing these alternatives 1
• Azithromycin has been shown to be clinically effective but may have lower bacteriologic eradication rates compared to penicillin 3, 4

Duration of Therapy

• The standard 10-day course of antibiotics is strongly recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 2
• Although shorter courses (5-7 days) of certain antibiotics have been studied, the Infectious Diseases Society of America does not currently recommend these shorter regimens due to insufficient comprehensive data and concerns about bacteriologic eradication 1, 5
• Azithromycin is the exception, with an FDA-approved 5-day course for streptococcal pharyngitis 3

Management of Recurrent Episodes

• For patients with recurrent episodes of GAS pharyngitis shortly after completing treatment, retreatment with the same antimicrobial agent is appropriate 1
• If compliance with oral therapy is questionable in recurrent cases, intramuscular benzathine penicillin G should be considered 1
• For multiple recurrences over months or years, clindamycin or amoxicillin/clavulanate may be beneficial as they have shown high rates of pharyngeal eradication of streptococci in carriers 1

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever associated with GAS pharyngitis 1, 2
• Aspirin should be avoided in children due to the risk of Reye syndrome 1, 2
• Corticosteroids are not recommended as adjunctive therapy despite some evidence of modest symptom reduction 1

Common Pitfalls to Avoid

• Overtreatment of likely viral pharyngitis (characterized by cough, rhinorrhea, hoarseness, oral ulcers) with antibiotics should be avoided 2
• Routine post-treatment throat cultures for asymptomatic patients who have successfully completed therapy are not recommended 1
• Testing or treating asymptomatic household contacts is not routinely recommended unless there is a history of rheumatic fever or increased risk of frequent infections 1
• Shorter antibiotic courses (except for FDA-approved 5-day azithromycin) should not be substituted for the standard 10-day regimen, despite patient preference for shorter treatment durations 1

Remember that proper diagnosis through either throat culture or rapid antigen detection test (RADT) is essential before initiating antibiotic therapy, as clinical features alone cannot reliably distinguish between viral and streptococcal pharyngitis 1, 2.