What is the recommended treatment for strep throat?

Recommended Treatment for Strep Throat

Penicillin or amoxicillin is the first-line treatment for strep throat 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:

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

• Oral amoxicillin for 10 days:

  • 50 mg/kg once daily (maximum = 1,000 mg) or
  • 25 mg/kg twice daily (maximum = 500 mg) 1, 2, 3

• Intramuscular benzathine penicillin G (single dose) for patients unlikely to complete a full 10-day oral course:

  • Patients < 60 lb (27 kg): 600,000 units
  • Patients ≥ 60 lb: 1,200,000 units 1, 4

Treatment for Patients with Penicillin Allergy

For patients with non-immediate penicillin allergy:

• First-generation cephalosporins (avoid in immediate hypersensitivity to penicillin):
  • Cephalexin: 20 mg/kg per dose twice daily (maximum = 500 mg per dose) for 10 days
  • Cefadroxil: 30 mg/kg once daily (maximum = 1 g) for 10 days 1, 5

For patients with immediate/severe penicillin allergy:

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

Diagnostic Considerations

• Testing is recommended for patients with clinical features suggesting streptococcal infection:

  • Sudden onset of sore throat, fever, headache
  • Tonsillopharyngeal inflammation or exudates
  • Tender anterior cervical lymphadenopathy 1, 2

• Testing is not recommended if clinical features strongly suggest viral etiology:

  • Cough, rhinorrhea, hoarseness, oral ulcers 1, 6

Adjunctive Therapy

• Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever 1, 2
• Avoid aspirin in children due to the risk of Reye syndrome 1, 2
• Corticosteroids are not recommended as adjunctive therapy 1, 5

Duration of Treatment

• A full 10-day course of antibiotics is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 4, 2
• Azithromycin is the exception, requiring only a 5-day course due to its prolonged tissue half-life 1, 5
• Patients are considered no longer contagious after 24 hours of appropriate antibiotic therapy 4

Important Considerations and Pitfalls

• Macrolide resistance (azithromycin, clarithromycin) among Group A Streptococcus varies geographically and temporally, with rates around 5-8% in the United States 5, 7

• Routine post-treatment throat cultures are not recommended for asymptomatic patients who have completed therapy 1, 4

• For recurrent streptococcal pharyngitis, consider:

  • Retreating with the same agent used initially
  • Using intramuscular benzathine penicillin G if compliance with oral therapy is questionable
  • Using clindamycin for chronic carriers due to its high efficacy in eradicating streptococci 5, 4, 2

• BID (twice daily) dosing of penicillin is as efficacious as more frequent dosing regimens, which can improve compliance 8

• Once-daily dosing of penicillin is associated with decreased efficacy and should not be used 8