What are the treatment options for streptococcal pharyngitis?

Treatment Options for Streptococcal Pharyngitis

Penicillin or amoxicillin remains the 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 with 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 2
• Amoxicillin is an equally effective alternative to penicillin V, particularly for young children due to better taste acceptance of the suspension 1
• Once-daily amoxicillin (50 mg/kg, maximum 1,000 mg) for 10 days has been shown to be effective and may enhance adherence due to convenient dosing 1, 2
• Intramuscular benzathine penicillin G as a single dose is recommended for patients unlikely to complete a full 10-day oral course, with dosage of 600,000 units for patients < 60 lb and 1,200,000 units for patients ≥ 60 lb 2

Treatment Options for Penicillin-Allergic Patients

• For patients with non-anaphylactic penicillin allergy, a 10-day course of oral first-generation cephalosporins (e.g., cefadroxil or cephalexin) is recommended 1, 3
• For patients with anaphylactic penicillin allergy, 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 1, 3
  • Azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days 1, 3

Medications to Avoid

• Tetracyclines should not be used due to high prevalence of resistant strains 1
• Sulfonamides and trimethoprim-sulfamethoxazole should not be used as they do not eradicate GAS from patients with acute pharyngitis 1
• Older fluoroquinolones (e.g., ciprofloxacin) have limited activity against GAS and should not be used 1
• Newer fluoroquinolones (e.g., levofloxacin, moxifloxacin) are unnecessarily broad-spectrum and expensive, and therefore not recommended 1

Duration of Treatment

• A standard 10-day course of antibiotics is recommended for most agents to ensure complete eradication of the organism and prevent rheumatic fever 1, 2
• FDA-approved 5-day courses include azithromycin, cefdinir, and cefpodoxime, though the broader spectrum and higher cost of these options make them less preferable than penicillin or amoxicillin 1

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 2
• Aspirin should be avoided in children due to the risk of Reye syndrome 2, 3

Management of Recurrent Cases

• For recurrent pharyngitis, retreatment with the same agent used initially is recommended 2
• Consider intramuscular benzathine penicillin G if compliance with oral therapy is questionable 2
• Clindamycin or amoxicillin/clavulanate may be considered for chronic carriers 2

Common Pitfalls to Avoid

• Overtreatment of likely viral pharyngitis (presenting with cough, rhinorrhea, hoarseness, oral ulcers) 2
• Routine post-treatment throat cultures for asymptomatic patients are not recommended 1, 2
• Using macrolides in areas with high resistance rates (resistance rates in the US are around 5-8%) 1
• Failing to complete the full course of antibiotics, which may lead to treatment failure and potential complications 4

Remember that a 10-day course of treatment is critical for streptococcal pharyngitis to prevent complications such as rheumatic fever, even though symptoms typically improve within 24-48 hours of starting antibiotics 1, 5.