What is the recommended treatment for strep throat?

Treatment of Streptococcal Pharyngitis

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

First-Line Treatment Options

• For patients without penicillin allergy, oral penicillin V for 10 days (250 mg 2-3 times daily for children; 250 mg four times daily or 500 mg twice daily for adolescents and adults) is recommended 2, 1
• Amoxicillin is equally effective and can be given as 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) for 10 days 2, 1, 3
• Intramuscular benzathine penicillin G as a single dose (600,000 units for patients <60 lb; 1,200,000 units for patients ≥60 lb) is preferred for patients unlikely to complete a full 10-day oral course 2, 1
• A full 10-day course is recommended to ensure complete eradication of the organism and prevent rheumatic fever 2, 1, 3

Treatment Options for Penicillin-Allergic Patients

• For patients with non-anaphylactic penicillin allergy, first-generation cephalosporins such as cephalexin (20 mg/kg twice daily, maximum 500 mg per dose) or cefadroxil (30 mg/kg once daily, maximum 1 g) for 10 days are recommended 2, 4
• For patients with anaphylactic penicillin allergy, the following options are available:
  • Clindamycin (7 mg/kg three times daily, maximum 300 mg per dose) for 10 days 2, 4
  • Clarithromycin (7.5 mg/kg twice daily, maximum 250 mg per dose) for 10 days 2, 4
  • Azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days 2, 4

Important Considerations

• Resistance to macrolides (azithromycin and clarithromycin) varies geographically and should be considered when selecting treatment 2, 4, 5
• Complete the full course of antibiotics even if symptoms improve, to prevent complications like rheumatic fever 1, 3
• Twice-daily dosing of penicillin is as effective as more frequent dosing regimens, which may improve compliance 6
• Once-daily dosing of penicillin is associated with decreased efficacy and should not be used 6

Treatment for Recurrent Streptococcal Pharyngitis

• For recurrent infections, consider whether the patient is a chronic carrier with viral infections or experiencing true recurrent bacterial infections 4, 7
• Treatment options for recurrent cases include:
  • Clindamycin (300 mg three times daily for adults) for 10 days 2, 7
  • Amoxicillin/clavulanate (875 mg twice daily for adults) for 10 days 2, 7
  • Penicillin plus rifampin (penicillin for 10 days plus rifampin for the last 4 days) 2, 7

Adjunctive Therapy

• Acetaminophen or NSAIDs are recommended for moderate to severe symptoms or high fever 2, 4, 1
• Aspirin should be avoided in children due to the risk of Reye syndrome 2, 4
• Corticosteroids are not recommended for routine use 4, 1, 8

Common Pitfalls to Avoid

• Overdiagnosis and overtreatment of viral pharyngitis as bacterial infection 4, 1, 8
• Failing to distinguish between true recurrent infections and chronic carriage with viral infections 4, 7
• Using macrolides in areas with high resistance rates 2, 4, 5
• Shorter antibiotic courses (5-7 days) may be effective according to some recent research, but the standard 10-day course remains recommended to prevent rheumatic fever 9, 1
• Penicillin failure rates have increased over time (up to approximately 30%), often due to poor compliance with the 10-day regimen 10