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, 2

First-Line Treatment Options

• For patients without penicillin allergy, oral penicillin V for 10 days is recommended at a dosage of 250 mg four times daily or 500 mg twice daily for adolescents and adults 2
• For children without penicillin allergy, oral amoxicillin for 10 days is recommended at a dosage of 50 mg/kg once daily (maximum = 1,000 mg) or 25 mg/kg twice daily (maximum = 500 mg) 2
• Intramuscular benzathine penicillin G (single dose) is recommended for patients unlikely to complete a full 10-day oral course, with a dosage of 600,000 units for patients < 60 lb (27 kg) and 1,200,000 units for patients ≥ 60 lb 2
• The standard 10-day course of antibiotics is necessary to ensure complete eradication of the organism and prevent rheumatic fever 1, 2

Treatment Options for Penicillin-Allergic Patients

• For patients with non-anaphylactic penicillin allergy, first-generation cephalosporins such as cephalexin (20 mg/kg per dose twice daily, maximum 500 mg per dose) or cefadroxil (30 mg/kg once daily, maximum 1 g) for 10 days are recommended 3
• For patients with anaphylactic sensitivity to penicillin, the following options are recommended:
  • Clindamycin (7 mg/kg per dose three times daily, maximum 300 mg per dose) for 10 days 1, 3
  • Clarithromycin (7.5 mg/kg per dose twice daily, maximum 250 mg per dose) for 10 days 3
  • Azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days 1, 3

Diagnostic Considerations

• Testing is not recommended for patients with clinical features suggesting viral etiology (e.g., cough, rhinorrhea, hoarseness, oral ulcers) 1, 2
• A positive rapid antigen detection test (RADT) is diagnostic for group A streptococcal pharyngitis 2
• A backup throat culture is recommended for children and adolescents with negative RADT results 2
• Diagnostic testing is not indicated for children under 3 years old because acute rheumatic fever is rare in this age group 1

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 1, 2
• Aspirin should be avoided in children due to the risk of Reye syndrome 1, 2
• Adjunctive therapy with corticosteroids is not recommended 1, 3

Management of Recurrent Streptococcal Pharyngitis

• Consider whether the patient is experiencing true recurrent infections or is a chronic carrier with viral infections 1, 3
• For recurrent pharyngitis, options include:
  • Retreatment with the same agent used initially 2
  • Intramuscular benzathine penicillin G if compliance with oral therapy is questionable 2
  • Clindamycin or amoxicillin/clavulanate for chronic carriers 2

Common Pitfalls to Avoid

• Overtreatment by prescribing antibiotics for likely viral pharyngitis (with cough, rhinorrhea, hoarseness, oral ulcers) 1, 2
• Using macrolides (azithromycin and clarithromycin) in areas with high resistance rates 3, 4
• Failing to distinguish between true recurrent infections and chronic carriage with viral infections 3
• Routine post-treatment throat cultures for asymptomatic patients are not recommended 1, 2
• Diagnostic testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1

Efficacy Considerations

• While penicillin has been the standard treatment for decades, some studies have reported increasing bacteriologic failure rates over time 5
• Amoxicillin at 40 mg/kg/day has shown higher clinical and bacteriologic cure rates compared to lower dosages of penicillin V in some studies 6
• Azithromycin has demonstrated clinical success rates of 95% for bacteriologic eradication in streptococcal pharyngitis, compared to 73% for penicillin V 7
• However, resistance to macrolides varies geographically and should be considered when selecting treatment 3, 4