What is the recommended treatment approach for a patient diagnosed with strep throat?

Treatment Approach for Strep Throat

Penicillin remains the treatment of choice for strep throat (Group A streptococcal pharyngitis) due to its proven efficacy, safety, narrow spectrum, and low cost, with a standard 10-day course recommended to prevent complications such as acute rheumatic fever. 1, 2

Diagnosis

• Diagnosis should be confirmed with either a rapid antigen detection test (RADT) or throat culture before initiating treatment 2
• A positive RADT is diagnostic and does not require backup culture 2
• A negative RADT in children and adolescents should be followed by a throat culture due to lower sensitivity of RADTs 2
• Clinical features alone cannot reliably distinguish between viral and bacterial pharyngitis 2

First-Line Treatment Options

• Oral penicillin V for 10 days:
  • For adolescents and adults: 250 mg four times daily or 500 mg twice daily 2
  • Twice-daily dosing is as effective as more frequent dosing regimens 3
• Amoxicillin for 10 days:
  • 50 mg/kg once daily (maximum 1,000 mg) 2
  • May enhance adherence due to better taste and once-daily dosing option 2
  • FDA label recommends at least 10 days of treatment for any infection caused by Streptococcus pyogenes 4
• Intramuscular benzathine penicillin G:
  • 1.2 million units as a single dose 2
  • Preferred for patients who are unlikely to complete a full 10-day course of oral therapy 1

Treatment for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy:
  • First-generation cephalosporins such as cephalexin (20 mg/kg per dose twice daily, maximum 500 mg per dose) or cefadroxil (30 mg/kg once daily, maximum 1 g) for 10 days 5, 2
• For anaphylactic penicillin allergy:
  • Clindamycin (7 mg/kg per dose three times daily, maximum 300 mg per dose) for 10 days 5
  • Clarithromycin (7.5 mg/kg per dose twice daily, maximum 250 mg per dose) for 10 days 5
  • Azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days 5, 6

Adjunctive Therapy

• Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 5, 2
• Aspirin should be avoided in children due to the risk of Reye syndrome 5, 2
• Warm salt water gargles can provide symptom relief for patients old enough to gargle 7

Management of Recurrent Strep Throat

• Confirm each recurrent episode with RADT or throat culture 5
• Consider whether the patient is experiencing true recurrent infections or is a chronic carrier with viral infections 5, 2
• For true recurrent infections:
  • Treat with one of the antimicrobial agents appropriate for treatment of the initial illness 1
  • If previous episodes were treated with oral agents and compliance is in question, consider intramuscular benzathine penicillin G 1
• For chronic carriers with multiple episodes over months or years:
  • Consider clindamycin or amoxicillin/clavulanate, which have shown high rates of pharyngeal eradication of streptococci 1

Common Pitfalls to Avoid

• Treating without confirming diagnosis through testing 2
• Prescribing broad-spectrum antibiotics unnecessarily when narrow-spectrum options are effective 2
• Using macrolides in areas with high resistance rates 5, 8
• Overdiagnosis and overtreatment of viral pharyngitis as bacterial infection 7
• Poor compliance with 10-day penicillin regimen, which is a major cause of treatment failure 9
• Using once-daily dosing of penicillin, which is associated with decreased efficacy (12 percentage points lower cure rate) 3

Follow-Up Recommendations

• Routine post-treatment throat cultures are not recommended unless symptoms persist or recur 2
• Treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic 4