What is the treatment for strep throat?

Treatment of Strep Throat

Penicillin V is the first-line treatment for strep throat, administered as 250 mg two to three times daily for children or 250 mg four times daily (or 500 mg twice daily) for adolescents and adults for 10 days. 1

Diagnosis and Clinical Presentation

Before initiating treatment, proper diagnosis is essential:

• Strep throat is caused by Group A β-hemolytic streptococcus (GABHS) 1
• Common symptoms include sudden onset of sore throat, fever, headache, nausea, vomiting, tonsillar exudates, and anterior cervical adenitis 1
• Diagnosis is confirmed through throat culture or rapid antigen detection testing 1
• The Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) can help assess the likelihood of strep throat 1

First-Line Antibiotic Treatment

• Penicillin V remains the treatment of choice due to its proven efficacy, safety, narrow spectrum, and low cost 1
• For children: 250 mg orally 2-3 times daily for 10 days 1
• For adolescents and adults: 250 mg orally 4 times daily or 500 mg twice daily for 10 days 1
• Amoxicillin is an acceptable alternative, particularly for young children due to better taste acceptance 1
• The full 10-day course must be completed to prevent complications, even if symptoms resolve earlier 2
• Benzathine penicillin G (intramuscular) is an alternative when oral compliance is a concern: 600,000 units for patients <60 lbs and 1,200,000 units for patients ≥60 lbs 1

Alternative Antibiotics for Penicillin-Allergic Patients

For patients with penicillin allergy, the following alternatives are recommended:

• First-generation cephalosporins (if no immediate hypersensitivity to β-lactams) 1
• Clindamycin: 7 mg/kg three times daily (max 300 mg per dose) for 10 days 1
• Macrolides such as azithromycin (12 mg/kg once daily, max 500 mg, for 5 days) or clarithromycin (7.5 mg/kg twice daily, max 250 mg per dose, for 10 days) 1, 3

Symptomatic Treatment

• Acetaminophen or NSAIDs (like ibuprofen) are recommended for pain and fever relief 1
• Avoid aspirin in children due to the risk of Reye syndrome 1
• Corticosteroids are not recommended for routine treatment of strep throat 1
• Adequate hydration and rest are important supportive measures 1

Treatment Duration Considerations

• The standard 10-day course of antibiotics is recommended to ensure complete eradication of GABHS 1
• Although some newer studies suggest shorter courses (5-7 days) may be effective 4, the most recent guidelines still recommend the full 10-day course to prevent complications like rheumatic fever 1

Special Considerations

• Antibiotics should not be used in patients with less severe presentation (0-2 Centor criteria) 1
• For patients with more severe presentations (3-4 Centor criteria), antibiotics may provide modest benefits in symptom reduction (1-2 days) 1
• The benefits of antibiotics must be weighed against potential side effects, impact on microbiota, increased antibiotic resistance, and costs 1
• Group A streptococci have not developed resistance to penicillin over five decades 1

Common Pitfalls and Caveats

• Failure to complete the full antibiotic course may lead to treatment failure and complications 2
• Distinguishing between viral pharyngitis and strep throat is crucial to avoid unnecessary antibiotic use 1
• Chronic GABHS carriers generally do not require treatment as they are at low risk of developing complications or transmitting disease 1, 5
• Tonsillectomy is not recommended solely to reduce the frequency of strep throat episodes 1
• Post-treatment testing is not routinely recommended for asymptomatic patients 1