What is the recommended treatment for strep throat?

Treatment of Strep Throat

Penicillin or amoxicillin is the first-line treatment for strep throat 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:

  • Children: 250 mg two or three times daily
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily 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, 2, 3

• Intramuscular benzathine penicillin G (single dose) for patients unlikely to complete a full 10-day oral course:

  • Patients < 60 lb (27 kg): 600,000 units
  • Patients ≥ 60 lb: 1,200,000 units 1, 2

Alternative Treatment for Penicillin-Allergic Patients

For patients with non-anaphylactic penicillin allergy:

• First-generation cephalosporins (10-day course):
  • Cephalexin: 20 mg/kg per dose twice daily (maximum = 500 mg per dose)
  • Cefadroxil: 30 mg/kg once daily (maximum = 1 g) 1, 4

For patients with immediate/anaphylactic penicillin allergy:

• Clindamycin: 7 mg/kg per dose three times daily (maximum = 300 mg per dose) for 10 days 1, 4
• Azithromycin: 12 mg/kg once daily (maximum = 500 mg) for 5 days 1, 4, 5
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum = 250 mg per dose) for 10 days 1, 4

Diagnostic Considerations

Testing is recommended for patients with clinical features suggesting streptococcal infection:

• Sudden onset of sore throat
• Fever (temperature greater than 100.4°F/38°C)
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough, rhinorrhea, hoarseness, or oral ulcers 1, 2

A positive rapid antigen detection test (RADT) is diagnostic for group A streptococcal pharyngitis. A backup throat culture is recommended for children and adolescents with negative RADT results 1, 2.

Duration of Therapy

A standard 10-day course of antibiotics is strongly recommended to ensure complete eradication of the organism and prevent rheumatic fever 1, 2. The only exception is azithromycin, which requires only a 5-day course due to its prolonged tissue half-life 1, 5.

While some studies have explored shorter treatment durations (5-7 days), the most recent guidelines still recommend the full 10-day course for most antibiotics 6, 1.

Adjunctive Therapy

• Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever 1
• Aspirin should be avoided in children due to the risk of Reye syndrome 1
• Corticosteroids are not recommended as adjunctive therapy 1, 4

Special Considerations

• Twice-daily dosing of penicillin is as effective as more frequent dosing regimens 7
• Once-daily amoxicillin therapy appears to be effective and may improve compliance 1, 7
• For patients with recurrent pharyngitis, consider:
  • Retreatment with the same agent used initially
  • Intramuscular benzathine penicillin G if compliance with oral therapy is questionable
  • Clindamycin for suspected chronic carriers 1, 2

Common Pitfalls to Avoid

• Prescribing antibiotics for likely viral pharyngitis (with cough, rhinorrhea, hoarseness, oral ulcers) 1, 2
• Using macrolides in areas with high rates of macrolide resistance 4, 8
• Routine post-treatment throat cultures for asymptomatic patients are not recommended 1
• Assuming all penicillin-allergic patients cannot receive cephalosporins (only those with immediate/anaphylactic reactions should avoid them) 1, 4
• Using shorter courses than recommended (except for azithromycin) can lead to treatment failure and complications 1