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

Treatment of Strep Throat in Teenagers

Penicillin or amoxicillin for 10 days is the recommended first-line treatment for teenagers diagnosed with strep throat due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1, 2

First-Line Treatment Options

• For teenagers without penicillin allergy, oral penicillin V for 10 days is recommended at a dose of 250 mg three or four times daily, or 500 mg twice daily 1
• Amoxicillin is an equally effective alternative to penicillin V, often preferred due to better taste and can be dosed at 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) for 10 days 1, 2, 3
• For teenagers who may have difficulty adhering to a 10-day oral regimen, a single intramuscular injection of benzathine penicillin G (1.2 million units) is an effective alternative 1, 2
• The full 10-day course must be completed even if symptoms resolve earlier, to ensure complete eradication of the organism and prevent complications such as acute rheumatic fever 1, 4

Treatment for Penicillin-Allergic Patients

• For teenagers with non-anaphylactic penicillin allergy, first-generation cephalosporins (e.g., cephalexin) for 10 days are recommended 1, 2
• For teenagers with immediate-type hypersensitivity to penicillin, the following options are available:
  • Clindamycin for 10 days 1, 2
  • Clarithromycin for 10 days 1, 2
  • Azithromycin for 5 days (note: there may be significant resistance to macrolides in some regions) 1, 2, 5

Diagnostic Considerations

• Diagnosis should be confirmed with rapid antigen detection test (RADT) and/or throat culture before initiating treatment 2, 6
• A positive RADT is diagnostic and does not require backup culture 2
• A negative RADT in teenagers should be followed by a throat culture to confirm the absence of streptococcal infection 1, 2, 6

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 1, 2
• Aspirin should be avoided in teenagers due to the risk of Reye syndrome 1, 2
• Corticosteroids are not recommended for routine use in streptococcal pharyngitis 1, 2

Treatment Challenges and Considerations

• Penicillin failure rates have increased over time, with current failure rates reported to be approximately 30% 7

• Primary causes of treatment failure include:

  • Poor adherence to the 10-day regimen 7
  • Reexposure to infected family members or peers 7
  • Copathogenicity with other bacterial strains 7
  • Antibiotic-associated eradication of normal protective pharyngeal flora 7

• While some studies suggest shorter antibiotic courses (5-7 days) may be effective 8, current guidelines still recommend the standard 10-day course to prevent complications like rheumatic fever 1, 2

• Patients with recurrent episodes should be evaluated to determine whether they are experiencing true recurrent infections or are chronic carriers with viral infections 2, 9

Common Pitfalls to Avoid

• Treating based on clinical symptoms alone without laboratory confirmation can lead to overuse of antibiotics 2, 6
• Discontinuing antibiotics prematurely once symptoms resolve, which can lead to treatment failure and complications 4
• Prescribing broad-spectrum antibiotics unnecessarily when narrow-spectrum options like penicillin are effective 1, 2
• Failing to consider compliance issues when selecting treatment; intramuscular benzathine penicillin G should be considered for patients unlikely to complete a full 10-day oral course 1, 10