Treatment of Streptococcal Pharyngitis
Penicillin or amoxicillin is the recommended 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 with 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, oral amoxicillin for 10 days (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
- Intramuscular benzathine penicillin G (single dose) is recommended for patients unlikely to complete a full 10-day oral course, with dosage of 600,000 units for patients <60 lb and 1,200,000 units for patients ≥60 lb 2
Treatment for Penicillin-Allergic Patients
- For patients with non-anaphylactic penicillin allergy, first-generation cephalosporins such as cephalexin (10-day course) are recommended 1, 4
- For patients with anaphylactic penicillin allergy, the following options are recommended:
Important Considerations
- A full 10-day course of antibiotics is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 2
- Macrolides (azithromycin, clarithromycin) may have variable resistance rates depending on geographic location 4, 5
- Penicillin resistance in Group A Streptococcus has never been documented 1
- Short-course penicillin therapy (<10 days) has been shown to be less effective than the standard 10-day course 6
Diagnostic Approach
- 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
- A positive rapid antigen detection test (RADT) is diagnostic for group A streptococcal pharyngitis 2
- Backup throat culture is recommended for children and adolescents with negative RADT results 2
Adjunctive Therapy
- Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 2, 7
- Aspirin should be avoided in children due to the risk of Reye syndrome 2, 7
Common Pitfalls to Avoid
- Overtreatment of viral pharyngitis with antibiotics should be avoided - clinical features suggesting viral etiology include cough, rhinorrhea, hoarseness, and oral ulcers 2, 7
- Follow-up throat cultures after treatment are not routinely recommended for asymptomatic patients 1
- Testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1
- Despite some evidence suggesting cephalosporins may be more effective for early clinical and microbiological cure, penicillin remains the first-line treatment due to its narrow spectrum and the critical importance of preserving the effectiveness of broader-spectrum antibiotics 6