What is the recommended treatment for a child with a positive strep (streptococcal) test?

Treatment of Streptococcal Pharyngitis in Children

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

First-Line Treatment Options

• Oral penicillin V for 10 days is the treatment of choice at a dose of 250 mg two to three times daily for children 1, 2
• Amoxicillin is often preferred for young children due to better taste acceptance, with a recommended dosage of 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 3
• A full 10-day course of antibiotics is essential to prevent acute rheumatic fever, even if symptoms resolve earlier 4, 3
• Intramuscular benzathine penicillin G is an alternative for patients unlikely to complete the full oral regimen: 600,000 units for patients <27 kg and 1,200,000 units for patients ≥27 kg (single dose) 1, 3

Treatment for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy, first-generation cephalosporins (e.g., cephalexin) are recommended for 10 days 1, 2
• For immediate-type hypersensitivity to penicillin, options include:
  • Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 3
  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 3
  • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1, 3
• Note that macrolide resistance has been reported in some geographic regions, potentially limiting effectiveness 5, 6

Diagnostic Considerations

• Diagnosis should be confirmed with rapid antigen detection test (RADT) and/or throat culture before initiating treatment 1, 7
• A positive RADT is diagnostic and does not require backup culture 7, 1
• A negative RADT in children should be followed by a throat culture due to lower sensitivity 7, 2
• Testing is generally not recommended in children younger than three years unless risk factors are present 7, 1

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or fever control 1, 3
• Aspirin should be avoided in children due to risk of Reye syndrome 1, 3
• Corticosteroids are not recommended for routine use in streptococcal pharyngitis 1, 2

Management of Household Contacts

• Routine testing or treatment of asymptomatic household contacts is not generally recommended 7
• Approximately 25% of asymptomatic household contacts harbor group A streptococci in their upper respiratory tracts 7
• In specific situations with increased risk of frequent infections or nonsuppurative sequelae, testing and treating household contacts may be considered 7

Follow-Up Recommendations

• Routine post-treatment testing is not recommended unless symptoms persist or recur 7, 3
• If symptoms persist beyond 48-72 hours, consider complications or treatment failure 3

Common Pitfalls to Avoid

• Treating without confirming diagnosis through testing, as clinical features alone cannot reliably distinguish between viral and bacterial pharyngitis 1, 2
• Using once-daily dosing of penicillin, which has been associated with higher treatment failure rates 8
• Prescribing broad-spectrum antibiotics unnecessarily when narrow-spectrum options are effective 1, 2
• Failing to complete the full 10-day course of antibiotics, which can lead to treatment failure and increased risk of rheumatic fever 4, 3
• Using macrolides (azithromycin, clarithromycin) as first-line therapy due to potential resistance issues in some regions 5, 6