Management of Streptococcal Pharyngitis
Penicillin or amoxicillin is 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 (250 mg 2-3 times daily for children; 250 mg four times daily or 500 mg twice daily for adolescents and adults) 2
- Amoxicillin for 10 days (50 mg/kg once daily, maximum 1000 mg; or 25 mg/kg twice daily, maximum 500 mg per dose) is equally effective and often preferred due to better taste and once-daily dosing option 1, 2
- Intramuscular benzathine penicillin G (single dose) is recommended for patients unlikely to complete a full 10-day oral course 2
Treatment for Penicillin-Allergic Patients
- First-generation cephalosporins (for those without anaphylactic sensitivity) for 10 days 1, 3
- Clindamycin (7 mg/kg per dose three times daily, maximum 300 mg per dose) for 10 days for patients with anaphylactic sensitivity 1, 3
- Clarithromycin (7.5 mg/kg per dose twice daily, maximum 250 mg per dose) for 10 days 3
- Azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days 1, 3, 4
Diagnostic Approach
- Testing is recommended for patients with clinical features suggesting streptococcal infection: sudden onset of sore throat, fever, headache, tonsillopharyngeal inflammation or exudates, and tender anterior cervical lymphadenopathy 2
- A positive rapid antigen detection test (RADT) is diagnostic for group A streptococcal pharyngitis 2
- Backup throat culture is recommended for children and adolescents with negative RADT results 2
Adjunctive Therapy
- Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1, 3, 2
- Aspirin should be avoided in children due to the risk of Reye syndrome 1, 3, 2
- Corticosteroids are not recommended for routine use 1, 3
Management of Recurrent Cases
- Consider whether the patient is experiencing true recurrent infections or is a chronic carrier with viral infections 1, 3
- For recurrent episodes, retreatment with the same agent used initially 2
- Consider intramuscular benzathine penicillin G if compliance with oral therapy is questionable 2
- Clindamycin or amoxicillin/clavulanate may be beneficial for chronic carriers 2
Duration of Treatment
- Standard 10-day course of antibiotics is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 2
- Azithromycin is FDA-approved for a 5-day course due to its prolonged tissue half-life 4
- Some newer studies suggest shorter courses (5-7 days) may be effective, but the standard recommendation remains 10 days for most antibiotics 5
Common Pitfalls to Avoid
- Overdiagnosis and overtreatment of viral pharyngitis as bacterial infection 3, 2
- Failing to distinguish between true recurrent infections and chronic carriage with viral infections 3, 2
- Using macrolides in areas with high resistance rates 3
- Unnecessary tonsillectomy solely to reduce frequency of GAS pharyngitis 1, 3
- Routine post-treatment throat cultures for asymptomatic patients are not recommended 1, 2
- Diagnostic testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1