What is the recommended treatment for strep throat?

Strep Throat Treatment

Penicillin or amoxicillin is the recommended 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:

  • < 60 lb (27 kg): 600,000 units
  • ≥ 60 lb: 1,200,000 units 1, 2

Treatment for Penicillin-Allergic Patients

• For non-immediate (non-anaphylactic) penicillin allergy:

  • 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, 4

• For severe or immediate penicillin allergy:

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

Important Treatment Considerations

• A full 10-day course of antibiotics is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 5, 2

• Azithromycin is the only exception requiring only a 5-day course due to its prolonged tissue half-life 4, 6

• Patients are generally considered non-contagious after 24 hours of appropriate antibiotic therapy 5

• Clinical improvement typically occurs within 24-48 hours of starting antibiotics, even though complete bacterial eradication may take longer 5, 7

Adjunctive Therapy

• Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever 1, 2

• Aspirin should not be used in children due to the risk of Reye syndrome 1, 4

• Corticosteroids are not recommended as adjunctive therapy 1, 4

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

• A positive rapid antigen detection test (RADT) is diagnostic for group A streptococcal pharyngitis 2

• A backup throat culture is recommended for children and adolescents with negative RADT results 2, 7

Treatment Failures and Recurrences

• For patients with recurrent pharyngitis, options include:
  • 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 5, 2

Common Pitfalls to Avoid

• Avoid prescribing antibiotics for likely viral pharyngitis (with cough, rhinorrhea, hoarseness, oral ulcers) 1, 7

• Avoid macrolides in areas with high resistance rates (resistance rates among Group A Streptococcus in the US range from 5-8%) 4, 7

• Routine post-treatment throat cultures are not recommended for asymptomatic patients who have completed therapy 5, 2

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