Guidelines for Treatment of Streptococcal Infections
Penicillin or amoxicillin for 10 days is the first-line treatment for streptococcal pharyngitis due to their proven efficacy, safety, narrow spectrum, and low cost. 1
First-Line Treatment Options
Oral Therapy
- Penicillin V for 10 days is the treatment of choice for non-allergic patients 1:
- Amoxicillin for 10 days is an equally effective alternative, often preferred for children due to better taste 1:
Intramuscular Therapy
- Benzathine penicillin G (single dose) is recommended for patients unlikely to complete oral therapy 1:
Treatment for Penicillin-Allergic Patients
For non-anaphylactic penicillin allergy, first-generation cephalosporins for 10 days 1:
For immediate-type hypersensitivity to penicillin 1:
- 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
Treatment Duration Considerations
- A full 10-day course of therapy is recommended for most antibiotics to achieve maximal pharyngeal eradication of streptococci and prevent rheumatic fever 1, 2
- Azithromycin is an exception, requiring only a 5-day course due to its prolonged tissue half-life 1
- Shorter courses of therapy (less than 10 days) with penicillin or amoxicillin are not recommended as they may not prevent rheumatic fever 1
Management of Treatment Failures and Carriers
- For patients with recurrent streptococcal pharyngitis or chronic carriers, consider 1:
- Clindamycin: 20-30 mg/kg per day in three doses (maximum 300 mg per dose) for 10 days
- Penicillin and rifampin combination: Penicillin V for 10 days plus rifampin 20 mg/kg per day for the last 4 days of treatment
- Amoxicillin/clavulanate: 40 mg amoxicillin per kg per day in three doses for 10 days
Diagnostic Considerations
- Confirm diagnosis with rapid antigen detection test (RADT) and/or throat culture before initiating treatment 1
- A positive RADT is diagnostic and does not require backup culture 1
- A negative RADT in children and adolescents should be followed by a throat culture 1
Adjunctive Therapy
- Consider analgesics or antipyretics (e.g., acetaminophen, NSAIDs) for moderate to severe symptoms or high fever 1
- Avoid aspirin in children due to risk of Reye syndrome 3
Common Pitfalls to Avoid
- Treating without confirming diagnosis through testing, as clinical features alone cannot reliably distinguish between viral and bacterial pharyngitis 1
- Using broad-spectrum antibiotics unnecessarily when narrow-spectrum options like penicillin are effective 1
- Prescribing shorter courses of therapy (less than 10 days) with penicillin or amoxicillin, which may not prevent rheumatic fever 1, 2
- Failing to ensure compliance with the full 10-day course of therapy, which is essential for preventing complications 4
- Using macrolides (azithromycin, clarithromycin) as first-line agents when local resistance patterns show high rates of Group A streptococcal resistance 1
Special Considerations
- Follow-up cultures after treatment are not routinely recommended unless symptoms persist or recur 1
- Testing or treatment of asymptomatic household contacts is not routinely recommended 1
- Consider testing and treating asymptomatic household contacts only when there is a high risk of frequent infections or non-suppurative sequelae 1
- Early treatment (within 48 hours of symptom onset) can reduce duration of symptoms and decrease risk of complications 4