What is the recommended treatment for strep throat?

Treatment of Strep Throat

Penicillin V or amoxicillin is the first-line treatment for strep throat, administered for 10 days to eradicate the infection and prevent complications. 1

First-Line Treatment Options

For patients without penicillin allergy:

• Penicillin V (oral):

  • Children: 250 mg two or three times daily for 10 days 1
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily for 10 days 1, 2

• Amoxicillin (oral):

  • 50 mg per kg once daily (maximum = 1,000 mg) for 10 days 1, 3
  • Alternative: 25 mg per kg twice daily (maximum = 500 mg) for 10 days 1, 3

• For patients unlikely to complete a full 10-day course of oral therapy:

  • Penicillin G benzathine (intramuscular):
    • < 60 lb (27 kg): 600,000 U as a single dose 1
    • ≥ 60 lb: 1,200,000 U as a single dose 1

Treatment for Penicillin-Allergic Patients

• First-generation cephalosporins (if no immediate hypersensitivity to penicillin):

  • Cephalexin (oral): 20 mg per kg per dose twice daily (maximum = 500 mg per dose) for 10 days 1
  • Cefadroxil (oral): 30 mg per kg once daily (maximum = 1 g) for 10 days 1

• For patients with immediate hypersensitivity to penicillin:

  • Clindamycin (oral): 7 mg per kg per dose three times daily (maximum = 300 mg per dose) for 10 days 1
  • Azithromycin (oral): 12 mg per kg once daily (maximum = 500 mg) for 5 days 1, 4
  • Clarithromycin (oral): 7.5 mg per kg per dose twice daily (maximum = 250 mg per dose) for 10 days 1

Important Considerations

Diagnostic Approach

• Testing is not recommended if clinical features strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers) 1
• Testing is generally not recommended in children younger than three years unless risk factors are present 1
• Follow-up post-treatment testing is not routinely recommended 1

Treatment Duration

• A full 10-day course of antibiotics is necessary to achieve maximal pharyngeal eradication of Group A streptococci 1, 5
• Azithromycin is an exception, requiring only a 5-day course due to its prolonged tissue half-life 1, 4

Adjunctive Therapy

• Analgesics or antipyretics (acetaminophen, NSAIDs) can be considered for moderate to severe symptoms or high fever 1
• Aspirin should not be used in children 1
• Corticosteroids are not routinely recommended 1

Potential Pitfalls

• Treatment Failure: Penicillin failure rates have increased over time to approximately 30%, primarily due to poor compliance with the 10-day regimen 5
• Resistance Concerns: Some strains of Group A streptococci have developed resistance to macrolides (azithromycin, clarithromycin), which varies geographically 1, 4
• Carrier State: Patients with recurrent pharyngitis may be chronic carriers experiencing repeated viral infections; antibiotics are not generally recommended in these cases 1

Special Situations

• Treatment of asymptomatic household contacts is not routinely recommended 1
• Consider treating household contacts when:
  • During community outbreaks of acute rheumatic fever or invasive Group A streptococcal infection 1
  • When the patient has a family or personal history of acute rheumatic fever 1
  • During outbreaks in closed or partially closed communities 1

Rationale for Treatment

• Early treatment of streptococcal pharyngitis can reduce symptom duration to less than 24 hours in most cases 6
• Treatment decreases the incidence of suppurative complications and limits spread of the disease 6
• Penicillin remains the drug of choice due to its narrow spectrum of activity, few adverse effects, modest cost, and no documented resistance 1
• The primary goal of treatment is to prevent acute rheumatic fever, particularly in high-risk patients 1, 7