What is the recommended treatment for strep throat?

Recommended Treatment for Strep Throat

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

First-Line Treatment Options

• Oral penicillin V for 10 days is the treatment of choice for strep throat (Group A Streptococcal pharyngitis) 1

  • Children: 250 mg two or three times daily for 10 days 1
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily for 10 days 1

• Amoxicillin is an acceptable alternative to penicillin V, particularly for young children due to better taste acceptance 1, 2

  • Dosage: 50 mg/kg once daily (maximum 1,000 mg) for 10 days 1
  • Alternative dosing: 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1

• Intramuscular benzathine penicillin G is recommended for patients unlikely to complete a full 10-day course of oral therapy 1, 3

  • Patients <60 lb (27 kg): 600,000 units as a single dose 1
  • Patients ≥60 lb: 1,200,000 units as a single dose 1

Treatment for Penicillin-Allergic Patients

• For patients with non-anaphylactic penicillin allergy, first-generation cephalosporins are recommended for 10 days 1

  • Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) 1
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g) 1

• For patients with immediate hypersensitivity to penicillin, alternative options include: 1

  • Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1
  • Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 1
  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 4

Duration of Treatment

• A full 10-day course of therapy is recommended for penicillin and most other antibiotics to achieve maximal pharyngeal eradication of Group A streptococci 1
• The 10-day duration is specifically important to prevent acute rheumatic fever, a serious complication of strep throat 2, 1
• Some newer agents (azithromycin, certain cephalosporins) may be effective with shorter courses (5 days), but these have broader spectrums and are generally more expensive 1

Important Clinical Considerations

• Patients are generally considered non-contagious after 24 hours of appropriate antibiotic therapy 3
• Clinical improvement typically occurs within 24-48 hours of starting antibiotics 3, 5
• Follow-up testing after completion of treatment is not routinely recommended for asymptomatic patients 1
• Patients with worsening symptoms after antibiotic initiation or with symptoms lasting 5 days after starting treatment should be reevaluated 5

Treatment of Recurrent Episodes

• For recurrent episodes of strep throat shortly after completing a course of antibiotics, treatment options include: 1, 3
  • Using the same antimicrobial agent as the initial treatment 3
  • Considering intramuscular benzathine penicillin G if compliance with oral therapy is questionable 1, 3
  • For multiple recurrences, alternative antibiotics such as clindamycin or amoxicillin/clavulanate may be beneficial due to their higher rates of pharyngeal eradication 1, 3

Common Pitfalls to Avoid

• Prescribing antibiotics without confirming diagnosis through rapid antigen detection test (RADT) or throat culture 1, 5
• Using broad-spectrum antibiotics as first-line treatment when narrow-spectrum options are effective 1
• Discontinuing antibiotics early when symptoms improve, rather than completing the full 10-day course 1, 2
• Using tetracyclines or sulfonamides, which have high rates of resistance among Group A streptococci 1
• Failing to consider the possibility of the patient being a streptococcal carrier with concurrent viral infection in cases of multiple recurrences 1, 3

Remember that penicillin resistance has never been documented in Group A streptococci, making it still the most reliable first-line treatment despite decades of use 1.