What is the recommended treatment for strep throat?

Treatment 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

First-Line Treatment Options

For Patients Without Penicillin Allergy:

• Oral penicillin V for 10 days:
  • Children: 250 mg two or three times daily
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily 2, 1
• Oral amoxicillin for 10 days:
  • 50 mg/kg once daily (maximum = 1,000 mg) or
  • 25 mg/kg twice daily (maximum = 500 mg) 2, 1
• Intramuscular benzathine penicillin G (single dose) for patients unlikely to complete a full 10-day oral course:
  • < 60 lb (27 kg): 600,000 units
  • ≥ 60 lb: 1,200,000 units 2

For Patients With Penicillin Allergy:

• For non-anaphylactic penicillin allergy:
  • Cephalexin (Keflex): 20 mg/kg per dose twice daily (maximum = 500 mg per dose) for 10 days 2, 3
  • Cefadroxil: 30 mg/kg once daily (maximum = 1 g) for 10 days 2, 3
• For anaphylactic penicillin allergy:
  • Clindamycin: 7 mg/kg per dose three times daily (maximum = 300 mg per dose) for 10 days 2, 3
  • Azithromycin: 12 mg/kg once daily (maximum = 500 mg) for 5 days 2, 3
  • Clarithromycin: 7.5 mg/kg per dose twice daily (maximum = 250 mg per dose) for 10 days 2, 3

Rationale for 10-Day Treatment

• A full 10-day course of antibiotics is recommended to ensure complete eradication of the organism from the pharynx and prevent rheumatic fever 2, 1
• The FDA label for amoxicillin specifically recommends at least 10 days' treatment for any infection caused by Streptococcus pyogenes to prevent acute rheumatic fever 4
• While some studies have explored shorter courses of newer antibiotics, the Infectious Diseases Society of America still recommends the conventional 10-day course for most oral antibiotics 2

Adjunctive Therapy

• Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever 2, 1
• Aspirin should be avoided in children due to the risk of Reye syndrome 2, 1
• Corticosteroids are not recommended for routine use in streptococcal pharyngitis 3, 5

Management of Treatment Failures and Recurrent Cases

• For recurrent pharyngitis shortly after completing treatment:
  • Retreatment with the same agent used initially 2, 1
  • Consider intramuscular benzathine penicillin G if compliance with oral therapy is questionable 2
• For chronic carriers with multiple recurrences:
  • Clindamycin: 20-30 mg/kg per day in three doses (maximum = 300 mg per dose) for 10 days 2
  • Amoxicillin/clavulanate: 40 mg amoxicillin per kg per day in three doses (maximum = 2,000 mg amoxicillin per day) for 10 days 2
  • Penicillin and rifampin combination therapy 2

Common Pitfalls to Avoid

• Overdiagnosing and overtreating viral pharyngitis as bacterial infection 3, 1
• Using macrolides (azithromycin, clarithromycin) in areas with high resistance rates 2, 3
• Failing to distinguish between true recurrent infections and chronic carriage with viral infections 3, 1
• Using once-daily dosing of penicillin V, which has been shown to be less effective than twice or four times daily dosing 6
• Stopping antibiotics early when symptoms improve, as this increases the risk of treatment failure and complications 4, 5
• Unnecessarily performing tonsillectomy solely to reduce frequency of streptococcal pharyngitis 3