What are the alternative treatments for strep throat?

Alternative Treatments for Strep Throat

Penicillin and amoxicillin remain the first-line treatments for strep throat, but several effective alternative treatments exist for patients who cannot take these medications. 1, 2

First-Line Treatment (For Reference)

• Penicillin V remains the treatment of choice for Group A Streptococcal (GAS) pharyngitis due to its proven efficacy, safety, narrow spectrum, and low cost 3, 1
• Amoxicillin (50 mg/kg/day once daily, maximum 1000 mg) for 10 days is an equally effective alternative with improved adherence due to convenient dosing 1
• Intramuscular benzathine penicillin G is preferred for patients unlikely to complete a full 10-day course of oral therapy 3, 2

Alternative Treatments Based on Penicillin Allergy Type

For Non-Anaphylactic Penicillin Allergy

• First-generation cephalosporins are recommended as first-line alternatives 4
  • Cephalexin: 20 mg/kg per dose twice daily for 10 days 4
  • Cefadroxil: 30 mg/kg once daily for 10 days 4
• These medications have strong evidence for efficacy in patients without immediate hypersensitivity to β-lactam antibiotics 3, 4

For Immediate/Anaphylactic Penicillin Allergy

• Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 4
• Macrolides (with caution due to resistance concerns) 3, 4:
  • Erythromycin: 20-40 mg/kg/day divided 2-3 times daily for 10 days 4
  • Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 4
  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 3, 5

Treatment Duration Considerations

• Most antibiotics require a full 10-day course to achieve maximal pharyngeal eradication of GAS 3, 2
• Azithromycin is the exception, requiring only a 5-day course due to its prolonged tissue half-life 5
• Recent research suggests shorter courses (5-7 days) of certain antibiotics may be effective, but this approach is not yet recommended in major guidelines 6, 7

For Recurrent Strep Throat

• For patients with multiple recurrences, alternative regimens may be more effective 3:
  • Clindamycin: 20-30 mg/kg/day in 3 divided doses for 10 days 3
  • Amoxicillin-clavulanate: 40 mg/kg/day in 3 divided doses for 10 days 3
  • Benzathine penicillin G with rifampin (20 mg/kg/day in 2 divided doses for 4 days) 3

Efficacy Considerations

• Cephalosporins may have higher bacterial eradication rates than penicillin in some studies 7
• Clindamycin demonstrates high efficacy in eradicating streptococci, even in chronic carriers 4
• Macrolide resistance among GAS varies geographically, with approximately 5-8% resistance in the United States 4

Important Clinical Considerations

• Patients are generally considered non-contagious after 24 hours of appropriate antibiotic therapy 2
• Routine follow-up testing after completion of antibiotic therapy is not recommended for patients who have successfully completed treatment 3, 2
• The primary goal of treatment is not only symptomatic improvement but also prevention of acute rheumatic fever 3
• Penicillin failure rates have increased over time, from 2-10% in the 1970s to approximately 30% more recently 8

Adjunctive Therapy

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

Common Pitfalls to Avoid

• Prescribing shorter courses than recommended (except for azithromycin) can lead to treatment failure and complications 1, 9
• Assuming all penicillin-allergic patients cannot receive cephalosporins (only those with immediate/anaphylactic reactions should avoid them) 4
• Using broad-spectrum antibiotics like Augmentin as first-line therapy increases costs and promotes antimicrobial resistance without providing additional clinical benefit 1