What is the recommended treatment for streptococcal pharyngitis?

Treatment of Streptococcal Pharyngitis

For patients with streptococcal pharyngitis, penicillin or amoxicillin is the recommended first-line treatment due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1, 2

First-Line Treatment Options

For Non-Penicillin Allergic Patients:

• Oral penicillin V for 10 days:

  • Children: 250 mg 2-3 times daily 1, 2
  • Adolescents and adults: 250 mg 3-4 times daily or 500 mg twice daily 1, 2

• Oral amoxicillin for 10 days:

  • 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) 1, 2
  • Amoxicillin is often preferred for young children due to better taste acceptance and once-daily dosing option, which may enhance adherence 1, 2

• Intramuscular benzathine penicillin G (single dose):

  • Patients <60 lb (27 kg): 600,000 units 1, 2
  • Patients ≥60 lb (27 kg): 1,200,000 units 1, 2
  • Preferred for patients unlikely to complete a full 10-day oral course 1

For Penicillin-Allergic Patients:

• For patients without anaphylactic sensitivity to penicillin:

  • First-generation cephalosporins for 10 days (e.g., cephalexin, cefadroxil) 1, 3

• For patients with anaphylactic sensitivity to penicillin:

  • Clindamycin for 10 days (7 mg/kg per dose three times daily, maximum 300 mg per dose) 1, 3
  • Clarithromycin for 10 days (7.5 mg/kg per dose twice daily, maximum 250 mg per dose) 1, 3, 4
  • Azithromycin for 5 days (12 mg/kg once daily, maximum 500 mg) 1, 3, 5

Important Clinical Considerations

• A full 10-day course of antibiotics (except for azithromycin) is necessary to ensure complete eradication of the organism and prevent rheumatic fever 1, 2

• Once-daily dosing of penicillin V is not recommended as it results in higher bacteriologic failure rates (22%) compared to multiple daily doses (8%) 6

• Twice-daily dosing of penicillin V (500 mg twice daily) appears to be as effective as three-times-daily dosing (250 mg three times daily) 7

• Clinical response to antibiotic therapy is typically achieved within 24-48 hours 1

• Streptococcal pharyngitis is generally a self-limited disease, but treatment helps prevent complications like rheumatic fever 1, 8

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 3, 2

• Aspirin should be avoided in children due to the risk of Reye syndrome 3, 2

Management of Household Contacts

• Routine testing or treatment of asymptomatic household contacts is not recommended 1

• In situations with repeated infections, consider performing cultures for asymptomatic family contacts and treating those with positive results 1

Common Pitfalls to Avoid

• Overdiagnosis and overtreatment of viral pharyngitis as bacterial infection 3, 2

• Using macrolides in areas with high resistance rates 3

• Using shorter courses of antibiotics than recommended (except for FDA-approved 5-day courses of specific antibiotics like azithromycin) 1

• Routine post-treatment throat cultures for asymptomatic patients are not recommended 1, 2

• Failing to distinguish between true recurrent infections and chronic carriage with viral infections 3