Treatment of Streptococcal Pharyngitis
For patients with confirmed group A streptococcal (GAS) 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
- Penicillin V is recommended for a 10-day course with dosage of 250 mg four times daily or 500 mg twice daily for adolescents and adults, and 250 mg two to three times daily for children 1, 2
- Amoxicillin is equally effective and often preferred for children due to better taste and once-daily dosing option: 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) for 10 days 1, 2
- Intramuscular benzathine penicillin G (single dose) is recommended for patients unlikely to complete a full 10-day oral course: 600,000 units for patients <60 lb (27 kg) and 1,200,000 units for patients ≥60 lb 2
- The standard 10-day course is necessary to ensure complete eradication of the organism and prevent rheumatic fever 2
- Once-daily amoxicillin has been shown to be effective and may enhance adherence compared to multiple daily doses 1, 3
Treatment for Penicillin-Allergic Patients
- For patients with non-anaphylactic penicillin allergy, first-generation cephalosporins (e.g., cephalexin) are recommended for a 10-day course 1, 4, 2
- For patients with anaphylactic sensitivity to penicillin, the following options are recommended:
- Be aware that macrolide resistance varies geographically and should be considered when selecting treatment 4, 5
Important Clinical Considerations
- A positive rapid antigen detection test (RADT) is diagnostic for GAS pharyngitis and does not require backup culture 4, 2
- For children and adolescents with negative RADT results, a backup throat culture is recommended 2
- Clinical response is usually achieved within 24-48 hours of appropriate antibiotic therapy 1
- Patients with worsening symptoms after antibiotic initiation or with symptoms lasting 5 days after starting treatment should be reevaluated 5
- Short-course penicillin therapy (<5 days) has been shown to be less effective than standard 10-day courses for clinical cure and bacterial eradication 6
- Short-course cephalosporin therapy may be more effective than long-course penicillin, but cephalosporins are considered "Highest Priority Critically Important Antimicrobials" and should be reserved for appropriate cases 6
Adjunctive Therapy
- Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 4, 2
- Aspirin should be avoided in children due to the risk of Reye syndrome 4, 7
- Corticosteroids are not recommended for routine use 4, 7
Common Pitfalls to Avoid
- Overdiagnosis and overtreatment of viral pharyngitis as bacterial infection 2, 7
- Using macrolides in areas with high resistance rates 4, 5
- Unnecessary tonsillectomy solely to reduce frequency of GAS pharyngitis 4, 5
- Routine post-treatment throat cultures for asymptomatic patients are not recommended 1
- Diagnostic testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1