What is the recommended treatment for strep throat?

Recommended Treatment for Strep Throat

Penicillin or amoxicillin is the first-line treatment for strep throat (group A streptococcal pharyngitis) due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1, 2, 3

First-Line Treatment Options

For patients without penicillin allergy:

• Oral penicillin V (10-day course):

  • Children: 250 mg two or three times daily
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily 1, 3

• Oral amoxicillin (10-day course):

  • 50 mg/kg once daily (maximum = 1,000 mg) or
  • 25 mg/kg twice daily (maximum = 500 mg) 1, 3, 4

• Intramuscular benzathine penicillin G (single dose) - for patients unlikely to complete a full 10-day oral course:

  • Patients < 60 lb (27 kg): 600,000 units
  • Patients ≥ 60 lb: 1,200,000 units 1, 2, 3

Alternative Treatment for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy:

  • Cephalexin (Keflex): 20 mg/kg twice daily (maximum = 500 mg per dose) for 10 days
  • Cefadroxil: 30 mg/kg once daily (maximum = 1 g) for 10 days 1, 3

• For immediate hypersensitivity to penicillin:

  • Clindamycin: 7 mg/kg three times daily (maximum = 300 mg per dose) for 10 days
  • Azithromycin: 12 mg/kg once daily (maximum = 500 mg) for 5 days
  • Clarithromycin: 7.5 mg/kg twice daily (maximum = 250 mg per dose) for 10 days 1, 2, 3

CAUTION: There is significant resistance to azithromycin and clarithromycin in some parts of the United States 5

Duration of Treatment

• A standard 10-day course is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 2, 3
• Patients are considered non-contagious after 24 hours of appropriate antibiotic therapy 2
• The full 10-day course must be completed even if symptoms resolve earlier 1, 3

Adjunctive Therapy

• Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1, 3
• Avoid aspirin in children due to the risk of Reye syndrome 1, 3
• Corticosteroids are not recommended for symptomatic treatment 1, 5

Diagnostic Considerations

• Testing is recommended for patients with clinical features suggesting streptococcal infection:

  • Sudden onset of sore throat
  • Fever
  • Headache
  • Tonsillopharyngeal inflammation or exudates
  • Tender anterior cervical lymphadenopathy 1, 3

• Testing is not recommended if clinical features strongly suggest a viral etiology (e.g., cough, rhinorrhea, hoarseness, oral ulcers) 1, 3

Treatment Failures and Recurrences

• For recurrent pharyngitis, consider:
  • Retreatment with the same agent used initially
  • Intramuscular benzathine penicillin G if compliance with oral therapy is questionable
  • Alternative antibiotics such as clindamycin or amoxicillin/clavulanate for chronic carriers 2, 3

Common Pitfalls to Avoid

• Overtreatment of likely viral pharyngitis 1, 3
• Incomplete antibiotic course leading to treatment failure 6
• Unnecessary post-treatment throat cultures for asymptomatic patients 1, 3
• Using once-daily penicillin dosing, which is associated with decreased efficacy (twice-daily dosing is acceptable) 7

Special Considerations

• While some studies suggest that shorter courses (3-6 days) of newer antibiotics may be effective 8, the standard 10-day course remains recommended to prevent rheumatic fever 1, 2, 3
• Penicillin has not developed resistance in group A streptococci over at least five decades, making it a reliable first choice 1