What is the first line treatment for strep throat?

First-Line Treatment for Strep Throat

Penicillin V or amoxicillin is the first-line treatment for strep throat due to their proven efficacy, safety, narrow spectrum, and low cost. 1, 2

Recommended Antibiotic Regimens

First-Line Options:

• Penicillin V: The gold standard treatment for Group A β-hemolytic streptococcal (GABHS) pharyngitis 2, 1
  • Adults: 250 mg orally 4 times daily or 500 mg twice daily for 10 days 1
  • Children: 250 mg orally 2-3 times daily for 10 days 1
• Amoxicillin: An equally effective alternative to penicillin V 1, 2
  • Often preferred in younger children due to better taste acceptance and availability as syrup 2, 1
  • Standard dosing: 500 mg three times daily for 10 days (adults) 2

For Penicillin-Allergic Patients:

• First-generation cephalosporins (if no immediate hypersensitivity to β-lactams) 1, 3
• Clindamycin: 300 mg four times daily for 10 days 2, 1
• Macrolides such as azithromycin or clarithromycin 2, 4
  • Note: There is significant resistance to macrolides in some parts of the US 3
  • FDA label for azithromycin specifically notes: "Penicillin is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever" 4

Treatment Decision Algorithm

1. Assessment of Severity: Use Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) 1, 2

   • 0-2 Centor criteria: Antibiotics generally not recommended 2
   • 3-4 Centor criteria: Consider antibiotic therapy 2

2. Antibiotic Selection:

   • No penicillin allergy: Penicillin V or amoxicillin for 10 days 1, 2
   • Non-anaphylactic penicillin allergy: First-generation cephalosporins 1, 3
   • Severe penicillin allergy: Clindamycin or macrolides 2, 1

3. Duration of Treatment:

   • The full 10-day course must be completed to ensure eradication of GABHS and prevent complications like rheumatic fever 1, 3

Important Clinical Considerations

• Group A streptococci have not developed resistance to penicillin over five decades, making it an excellent first choice 2, 1
• The WHO Expert Committee recommends amoxicillin or phenoxymethylpenicillin (penicillin V) as first-choice antibiotics for streptococcal pharyngitis 2
• Although some studies suggest cephalosporins may have higher bacteriological cure rates, the clinical differences are not significant enough to warrant their use as first-line therapy 2
• Benzathine penicillin G (intramuscular) is an alternative when oral compliance is a concern 1, 5

Common Pitfalls to Avoid

• Using broad-spectrum antibiotics unnecessarily when narrow-spectrum penicillin is effective 2, 1
• Discontinuing antibiotics early (before completing the full 10-day course) 1, 3
• Using azithromycin as first-line therapy when penicillin or amoxicillin can be used 4
• Treating patients with likely viral pharyngitis (those with cough, coryza, or diarrhea) 1, 3
• Failing to consider the risk of Epstein-Barr virus-related rash when using amoxicillin in older children 2