Treatment of Streptococcal Pharyngitis
Penicillin or amoxicillin remains the treatment of choice for streptococcal pharyngitis due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1
First-Line Treatment Options
- For patients without penicillin allergy, oral penicillin V for 10 days is recommended at a 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
- Amoxicillin is an equally effective alternative, administered as 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) for 10 days 1
- For patients unlikely to complete a full 10-day oral course, intramuscular benzathine penicillin G as a single dose is preferred (600,000 units for patients <60 lb/27 kg; 1,200,000 units for patients ≥60 lb) 1
- Twice-daily dosing of penicillin is as effective as more frequent dosing regimens, which can improve compliance 2
Treatment for Penicillin-Allergic Patients
- For patients with 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 are recommended 3, 1
- For patients with anaphylactic penicillin sensitivity, clindamycin (7 mg/kg per dose three times daily, maximum 300 mg per dose) for 10 days is recommended 3
- Alternative options for severe penicillin allergy include clarithromycin (7.5 mg/kg per dose twice daily, maximum 250 mg per dose) for 10 days or azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days 3
- Caution should be exercised with macrolides (azithromycin and clarithromycin) due to variable geographic resistance patterns 3, 4
Duration of Treatment
- A standard 10-day course of antibiotics is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1
- While shorter courses (5-7 days) of certain antibiotics have shown comparable efficacy in some studies 5, 6, definitive results from comprehensive studies are not available, and shorter courses cannot be recommended at this time 7
- Azithromycin is an exception, requiring only a 5-day course due to its prolonged tissue half-life 3, 4
Management of Recurrent Streptococcal Pharyngitis
- For recurrent episodes, retreatment with the same agent used initially is appropriate 1
- If compliance with oral therapy is questionable, intramuscular benzathine penicillin G should be considered 7, 1
- For patients with multiple recurrences, clindamycin or amoxicillin/clavulanate may be beneficial as they have shown high rates of pharyngeal eradication of streptococci 7, 1
- It's important to distinguish between true recurrent infections and chronic carriage with viral infections 3
Adjunctive Therapy
- Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 3, 1
- Aspirin should be avoided in children due to the risk of Reye syndrome 3, 1
- Corticosteroids are not recommended for routine use 3
Common Pitfalls to Avoid
- Overdiagnosis and overtreatment of viral pharyngitis as bacterial infection 3, 1
- Failing to distinguish between true recurrent infections and chronic carriage with viral infections 3
- Using macrolides in areas with high resistance rates 3, 4
- Once-daily dosing of penicillin is associated with decreased efficacy and should not be used 2
- Bacteriologic failure rates with penicillin therapy have increased over time, now reported to be approximately 30%, primarily due to lack of compliance with the 10-day regimen 8
- Unnecessary tonsillectomy solely to reduce frequency of streptococcal pharyngitis should be avoided 3, 9