What is the appropriate treatment for a 25-year-old female with a positive strep throat diagnosis and an oral penicillin (Penicillin) regimen prescribed?

Assessment and Plan: Group A Streptococcal Pharyngitis

Assessment

25-year-old female with positive strep throat test

• Confirmed Group A Streptococcal (GAS) pharyngitis by positive testing 1
• Appropriate candidate for oral antibiotic therapy given ability to tolerate oral medications and likely good compliance 1

Plan

Antibiotic Treatment

Prescribe Penicillin V 500 mg orally twice daily for 10 days 1

• Penicillin remains the treatment of choice due to proven efficacy, safety, narrow antimicrobial spectrum, and low cost 1
• Alternative dosing: 250 mg three to four times daily for 10 days is equally effective, though twice-daily dosing improves compliance 1
• The full 10-day course is essential to achieve maximal pharyngeal eradication of GAS and prevent rheumatic fever 1, 2

Patient Education and Counseling

Medication adherence:

• Emphasize completing the entire 10-day course even when symptoms improve after 24-48 hours 3, 2
• Skipping doses or stopping early decreases treatment effectiveness and increases bacterial resistance risk 2

Expected clinical course:

• Symptoms should improve within 24-48 hours of starting antibiotics 3
• Patient becomes non-contagious after 24 hours of appropriate antibiotic therapy 3
• May return to work/normal activities after 24 hours on antibiotics if feeling well 3

Warning signs:

• Contact physician if symptoms worsen or do not improve within 48-72 hours 2
• Seek immediate care for difficulty breathing, swallowing, or severe worsening 2
• Report watery or bloody diarrhea, even if occurring weeks after completing antibiotics (possible C. difficile infection) 2

Symptomatic Management

• Acetaminophen or NSAIDs for pain and fever control 4
• Adequate hydration and rest 4

Follow-Up

No routine follow-up testing needed:

• Do not perform throat culture after completing treatment if asymptomatic 3
• Routine post-treatment cultures are not recommended for patients who successfully complete therapy 3

Follow-up testing only indicated in special circumstances:

• History of rheumatic fever 3
• Outbreak situations 3
• Symptom recurrence within 2-4 weeks (may represent treatment failure or reinfection) 3

Important Caveats

If penicillin allergy:

• For non-anaphylactic allergy: First-generation cephalosporin (cephalexin 500 mg twice daily for 10 days) 4
• For immediate/anaphylactic allergy: Clindamycin 300 mg three times daily for 10 days OR azithromycin 500 mg once daily for 5 days 4
• Macrolide resistance is approximately 5-8% in the United States, making clindamycin preferable for severe allergies 4

Treatment failure considerations:

• If symptoms recur with positive testing shortly after completing therapy, retreat with same antibiotic or consider intramuscular benzathine penicillin G if compliance is questionable 3
• For multiple recurrences, consider clindamycin or amoxicillin-clavulanate due to higher eradication rates 3