What is the recommended treatment for streptococcal pharyngitis?

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, 2

First-Line Treatment Options

• For patients without penicillin allergy, oral penicillin V for 10 days is recommended at a dosage of 250 mg 2-3 times daily for children and 250 mg four times daily or 500 mg twice daily for adolescents and adults 1, 2
• Alternatively, amoxicillin for 10 days at 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) is equally effective and may improve compliance due to once-daily dosing 1, 2, 3, 4
• Intramuscular benzathine penicillin G as a single dose is recommended for patients unlikely to complete a full 10-day oral course 2

Treatment for Penicillin-Allergic Patients

• For patients with non-anaphylactic penicillin allergy, first-generation cephalosporins (e.g., cephalexin) for 10 days are recommended 1, 5
• For patients with anaphylactic penicillin allergy, the following options are recommended for 10 days:
  • Clindamycin (7 mg/kg per dose three times daily, maximum 300 mg per dose) 1, 5
  • Clarithromycin (7.5 mg/kg per dose twice daily, maximum 250 mg per dose) 1, 5
  • Azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days 1, 5

Diagnostic Considerations

• Testing is recommended for patients with clinical features suggesting streptococcal infection, including sudden onset of sore throat, fever, headache, tonsillopharyngeal inflammation or exudates, and tender anterior cervical lymphadenopathy 2, 6
• A positive rapid antigen detection test (RADT) is diagnostic for group A streptococcal pharyngitis 2
• For children and adolescents with negative RADT results, a backup throat culture is recommended 2, 7

Duration of Treatment

• A standard 10-day course of antibiotics is necessary to ensure complete eradication of the organism and prevent rheumatic fever 1, 2
• Short-course penicillin therapy (≤5 days) has been shown to be less effective for clinical cure and bacteriological eradication compared to standard 10-day courses 8

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 2
• Aspirin should be avoided in children due to the risk of Reye syndrome 2, 6

Special Considerations

• Follow-up post-treatment throat cultures are not recommended routinely for asymptomatic patients 1, 2
• Testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1
• For recurrent pharyngitis, consider:
  • Retreatment with the same agent used initially
  • Intramuscular benzathine penicillin G if compliance with oral therapy is questionable
  • Clindamycin or amoxicillin/clavulanate for chronic carriers 2, 5

Common Pitfalls to Avoid

• Overtreatment of viral pharyngitis with antibiotics (characterized by cough, rhinorrhea, hoarseness, oral ulcers) 2, 6
• Using macrolides (azithromycin, clarithromycin) in areas with high resistance rates 5, 9, 7
• Failing to distinguish between true recurrent infections and chronic carriage with viral infections 5
• Unnecessary tonsillectomy solely to reduce frequency of GAS pharyngitis 5, 7
• Using shorter courses of penicillin, which are less effective than the standard 10-day regimen 8