What is the treatment for pediatric strep throat?

Treatment of Pediatric Streptococcal Pharyngitis

Penicillin or amoxicillin for 10 days is the first-line treatment for pediatric streptococcal pharyngitis due to their proven efficacy, safety, narrow spectrum of activity, and low cost. 1, 2

First-Line Treatment Options

• For patients without penicillin allergy, oral penicillin V for 10 days is recommended: 250 mg two or three times daily for children 1, 3
• Amoxicillin is often used in place of penicillin V in younger children due to better palatability and availability as syrup or suspension: 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) for 10 days 1, 3
• Intramuscular benzathine penicillin G (single dose) is an alternative for patients unlikely to complete a full 10-day oral course: 600,000 units for patients <27 kg and 1,200,000 units for patients ≥27 kg 1, 3

Treatment for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy, first-generation cephalosporins (e.g., cephalexin) for 10 days are recommended 1, 2
• For immediate-type hypersensitivity to penicillin, clindamycin for 10 days: 7 mg/kg three times daily (maximum 300 mg per dose) 1, 3
• Alternatively, for immediate-type hypersensitivity, azithromycin for 5 days: 12 mg/kg once daily (maximum 500 mg) 1, 4
• Clarithromycin for 10 days: 7.5 mg/kg twice daily (maximum 250 mg per dose) is another option for penicillin-allergic patients 1, 5

Diagnostic Considerations

• Diagnosis should be confirmed 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 1, 2
• Testing is generally not recommended in children younger than three years unless risk factors are present 1

Duration of Therapy

• The standard 10-day course of antibiotics is recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 2
• Despite some studies suggesting shorter courses may be effective, current guidelines still recommend the full 10-day course for penicillin and amoxicillin 3
• While some newer antibiotics have been studied with shorter courses, definitive results from comprehensive studies are not available to endorse these shorter regimens 3

Adjunctive Therapy

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

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
• Prescribing broad-spectrum antibiotics unnecessarily when narrow-spectrum options are effective should be avoided 1, 2
• Routine post-treatment throat cultures are not recommended unless symptoms persist or recur 1
• Amoxicillin is a poor first choice in older children with suspected mononucleosis due to the risk of severe rash among patients with Epstein-Barr virus infection 3

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, primarily due to lack of compliance with the 10-day regimen 6
• Once-daily amoxicillin (50 mg/kg) has been shown to be as effective as penicillin V given three times daily for the treatment of streptococcal pharyngitis, which may improve compliance 7
• Recent research suggests that a single dose of amoxicillin (50 mg/kg) can result in nondetection of group A streptococci in 91% of children by the next morning, though the full 10-day course is still recommended to prevent complications 8