Treatment of Streptococcal Pharyngitis in Children
For children with streptococcal pharyngitis, penicillin or amoxicillin for 10 days is the recommended first-line treatment due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1, 2
First-Line Treatment Options
- Oral penicillin V for 10 days: 250 mg two or three times daily for children 1, 2
- Oral amoxicillin for 10 days: 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) 1, 3
- For patients unlikely to complete a full 10-day oral course, intramuscular benzathine penicillin G (single dose): 600,000 units for patients <27 kg and 1,200,000 units for patients ≥27 kg 1, 2
Treatment for Penicillin-Allergic Patients
- For non-anaphylactic penicillin allergy: first-generation cephalosporins (e.g., cephalexin) for 10 days 1
- For immediate-type hypersensitivity to penicillin:
Diagnostic Considerations
- Confirm diagnosis with rapid antigen detection test (RADT) and/or throat culture before initiating treatment 1, 2
- 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 6, 1
- Testing is generally not recommended in children younger than three years unless risk factors are present 1
Duration and Dosing Frequency
- The standard 10-day course is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 2
- Twice-daily dosing of penicillin is as effective as more frequent dosing regimens 7
- Once-daily dosing of penicillin is associated with decreased efficacy and should not be used 8, 7
Adjunctive Therapy
- Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1, 9
- Avoid aspirin in children due to risk of Reye syndrome 1, 9
Common Pitfalls to Avoid
- Treating without confirming diagnosis through testing should be avoided, as clinical features alone cannot reliably distinguish between viral and bacterial pharyngitis 1, 9
- Prescribing broad-spectrum antibiotics unnecessarily when narrow-spectrum options are effective 1
- Routine post-treatment throat cultures are not recommended unless symptoms persist or recur 1
- Failure to complete the full 10-day course of antibiotics, which is a primary cause of treatment failure 10
Special Considerations
- For recurrent episodes, evaluate whether the patient is experiencing true recurrent infections or is a chronic carrier with viral infections 1, 2
- Bacteriologic failure rates with penicillin therapy have increased over time and are now reported to be approximately 30% in some studies 10
- Early treatment of streptococcal pharyngitis can reduce symptom duration to less than 24 hours in most cases, decrease suppurative complications, limit disease spread, and permit earlier return to school 11