Best Antibiotics for Strep Throat

Penicillin V remains the first-line treatment of choice for strep throat due to its proven efficacy, safety, narrow spectrum, and low cost. 1, 2

First-Line Treatment Options

Penicillin V is the gold standard treatment for strep throat (Group A Streptococcal pharyngitis) 2, 1
- Children: 250 mg orally 2-3 times daily for 10 days 1
- Adolescents and adults: 250 mg orally 4 times daily or 500 mg twice daily for 10 days 2, 1
Amoxicillin is an equally effective alternative, particularly for young children due to better taste acceptance 2, 1
Benzathine penicillin G (intramuscular) is recommended when oral compliance is a concern 1
- Patients <60 lbs: 600,000 units as a single dose 1
- Patients ≥60 lbs: 1,200,000 units as a single dose 1

Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 3, 2
Macrolides (with caution due to resistance concerns) 2, 3:
- Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 2, 3
- Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 2, 4

Standard treatment duration is 10 days for most antibiotics to ensure complete eradication of Group A Streptococcus 2, 1
Azithromycin is the exception, requiring only a 5-day course due to its prolonged tissue half-life 4, 3
The full course must be completed to prevent complications like rheumatic fever, even if symptoms resolve earlier 1

Despite being the gold standard, penicillin treatment failure rates have increased from 2-10% in the 1970s to approximately 30% in recent years 5
Primary causes of penicillin treatment failure include poor compliance with the 10-day regimen, reexposure to infected individuals, and potential bacterial tolerance 5
Some studies suggest cephalosporins may have superior GABHS eradication rates compared to penicillin 5, 6
A Cochrane review found uncertain evidence of clinically relevant differences between cephalosporins, macrolides, and penicillin for symptom resolution 7

Macrolide resistance among Group A Streptococcus varies geographically and temporally 2, 3
Penicillin has not developed resistance despite decades of use 1
Routine post-treatment throat cultures are not recommended for asymptomatic patients who have completed therapy 3
Chronic GABHS carriers are at low risk of transmitting disease or developing invasive infections and generally do not require treatment 6
For treatment of chronic carriers when necessary, clindamycin (20-30 mg/kg/day in three doses for 10 days) has shown strong efficacy 2

For healthcare workers with pharyngeal carriage of Group A Streptococcus, treatment options include penicillin V (500 mg four times daily for 10 days), amoxicillin (500 mg three times daily for 10 days), clindamycin (300 mg four times daily for 10 days), or azithromycin (maximum 500 mg once daily for 3 days) 2
Clindamycin should be used for eradication of throat carriage when first-line therapy with penicillin has been unsuccessful 2