What is the recommended treatment for bacterial superimposed pharyngitis?

Treatment of Bacterial Superimposed Pharyngitis

For bacterial superimposed pharyngitis, penicillin or amoxicillin remains the first-line treatment of choice due to proven efficacy, safety, narrow spectrum, and low cost. 1

First-Line Treatment Options

• Penicillin V is recommended for a full 10-day course at 250 mg 2-4 times daily for adults or 250 mg 2-3 times daily for children 1, 2
• Amoxicillin is an excellent alternative, administered at 50 mg/kg once daily (maximum 1000 mg) for 10 days, with the advantage of once-daily dosing and better taste for children 1, 2
• Intramuscular benzathine penicillin G is preferred for patients unlikely to complete a full 10-day oral course, administered as a single dose 2

Treatment for Penicillin-Allergic Patients

• For patients with non-anaphylactic penicillin allergy, first-generation cephalosporins (e.g., cephalexin, cefadroxil) for 10 days are recommended 1, 3
• For patients with anaphylactic penicillin allergy, the following options are available:
  • Clindamycin (7 mg/kg three times daily, maximum 300 mg per dose) for 10 days 4, 2
  • Clarithromycin (7.5 mg/kg twice daily, maximum 250 mg per dose) for 10 days 4, 2
  • Azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days 4, 5

Important Considerations

• The full 10-day course of antibiotics (except for 5 days with azithromycin) is crucial to achieve maximal pharyngeal eradication of Group A Streptococcus and prevent complications 1
• Macrolide resistance varies geographically (around 5-8% in the US) and should be considered when selecting treatment 1, 3
• Certain antibiotics should be avoided:
  • Tetracyclines due to high prevalence of resistant strains 1
  • Sulfonamides and trimethoprim-sulfamethoxazole as they do not eradicate GAS 1
  • Older fluoroquinolones (e.g., ciprofloxacin) due to limited activity against GAS 1

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for symptomatic relief of moderate to severe symptoms or high fever 4, 2
• Aspirin should be avoided in children due to the risk of Reye syndrome 4, 2

Follow-Up Recommendations

• Routine post-treatment throat cultures are not recommended for asymptomatic patients who have completed therapy 1, 2
• Diagnostic testing or empiric treatment of asymptomatic household contacts is not routinely recommended 1

Common Pitfalls to Avoid

• Using first-generation cephalosporins in patients with immediate (anaphylactic-type) hypersensitivity to penicillin due to potential cross-reactivity (up to 10%) 1, 4
• Treating viral pharyngitis with antibiotics, as most cases of sore throat are viral 3, 2
• Using broad-spectrum antibiotics unnecessarily when narrow-spectrum options are effective 1, 3
• Prescribing shortened courses of antibiotics (except for FDA-approved 5-day azithromycin), as the standard 10-day course is necessary for complete eradication 1, 6