What is the recommended treatment for strep (streptococcal) throat in pediatric patients?

Treatment of Streptococcal Pharyngitis in Pediatric Patients

Penicillin or amoxicillin for 10 days is the recommended first-line treatment for streptococcal pharyngitis in pediatric patients 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 for 10 days: 250 mg two or three times daily for children 1
  • Oral amoxicillin for 10 days: 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) - preferred due to better palatability and enhanced adherence 1, 4
  • Intramuscular benzathine penicillin G (single dose): 600,000 units for patients <27 kg and 1,200,000 units for patients ≥27 kg - recommended when oral adherence is a concern 1

Treatment for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy:

  • First-generation cephalosporins (e.g., cephalexin) for 10 days 1
  • Clindamycin for 10 days: 7 mg/kg three times daily (maximum 300 mg per dose) 1

• For immediate-type hypersensitivity to penicillin:

  • Azithromycin for 5 days: 12 mg/kg once daily (maximum 500 mg) 1
  • Clarithromycin for 10 days: 7.5 mg/kg twice daily (maximum 250 mg per dose) 1

Diagnostic Considerations

• Confirm diagnosis with rapid antigen detection test (RADT) and/or throat culture before initiating treatment 2, 3
• A positive RADT is diagnostic and does not require backup culture 2
• A negative RADT in children and adolescents should be followed by a throat culture 2, 3
• Testing is generally not recommended in children younger than three years unless risk factors are present 1

Adjunctive Therapy

• Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1, 2
• Aspirin should be avoided in children due to risk of Reye syndrome 1, 2
• Corticosteroids are not recommended for routine use in streptococcal pharyngitis 5, 6

Duration of Therapy

• The standard 10-day course is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 4
• It is recommended that there be at least 10 days' treatment for any infection caused by Streptococcus pyogenes to prevent acute rheumatic fever 4
• Treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic 4

Common Pitfalls to Avoid

• Treating without confirming diagnosis through testing, as clinical features alone cannot reliably distinguish between viral and bacterial pharyngitis 3, 6
• Prescribing broad-spectrum antibiotics unnecessarily when narrow-spectrum options are effective 2, 3
• Using once-daily dosing of penicillin, which is associated with decreased efficacy (12 percentage points lower cure rate) 7
• Routine post-treatment throat cultures are not recommended unless symptoms persist or recur 1, 2

Special Considerations

• Patients with recurrent episodes should be evaluated to determine whether they are experiencing true recurrent infections or are chronic carriers with viral infections 2, 3
• While some recent studies suggest shorter antibiotic courses (5-7 days) may be effective 8, current guidelines still recommend the standard 10-day course to prevent complications like rheumatic fever 1, 4
• Penicillin treatment failure rates have increased from 2-10% in the 1970s to approximately 30% currently, primarily due to lack of compliance with the 10-day regimen 9