Treatment of Strep Throat in Pregnant Women
Penicillin V (500 mg orally twice daily for 10 days) or amoxicillin (500 mg orally three times daily for 10 days) are the recommended first-line treatments for strep throat in pregnant women. 1
First-Line Antibiotic Selection
Penicillin and cephalosporin antibiotics are the safest classes for treating bacterial pharyngitis during pregnancy, as they do not harm the fetus. 1 The Infectious Diseases Society of America guidelines establish penicillin as the drug of choice for group A streptococcal pharyngitis due to its narrow spectrum of activity. 1
Recommended Regimens:
- Penicillin V: 500 mg orally twice daily for 10 days 1, 2
- Amoxicillin: 500 mg orally three times daily for 10 days 1
- Intramuscular benzathine penicillin G: Single dose (useful when compliance is a concern) 1
The twice-daily penicillin V regimen is as effective as three-times-daily dosing and may improve compliance. 2
Management for Penicillin-Allergic Pregnant Women
Low-Risk Penicillin Allergy (No History of Anaphylaxis)
For pregnant women without a history of anaphylaxis, angioedema, respiratory distress, or urticaria following penicillin administration, cefazolin is the preferred alternative. 1
High-Risk Penicillin Allergy (History of Anaphylaxis)
For pregnant women at high risk for anaphylaxis, clindamycin (300 mg orally four times daily for 10 days) is recommended if susceptibility testing confirms the streptococcal isolate is susceptible to clindamycin. 1 If susceptibility is unknown or the isolate is resistant, alternative management should be discussed with infectious disease specialists. 1
Antibiotics to Avoid During Pregnancy
The following antibiotics should NOT be used during pregnancy as they pose fetal risks: 1
- Tetracyclines (including doxycycline)
- Aminoglycosides
- Trimethoprim-sulfamethoxazole
- Fluoroquinolones
Macrolides show uncertain efficacy compared to penicillin, and long-term macrolide use is not recommended during pregnancy. 1, 3
Important Clinical Considerations
Timing and Compliance
Early treatment of streptococcal pharyngitis reduces symptom duration to less than 24 hours in most cases, decreases suppurative complications, and limits disease spread. 4 In populations where compliance with oral antibiotics cannot be assured, intramuscular benzathine penicillin G remains the preferred treatment to ensure complete therapy. 1, 4
Diagnostic Confirmation
Treatment should be based on positive throat culture or rapid antigen detection testing (RADT) for group A streptococci. 1 Withholding antibiotics in patients with negative microbiological tests is a quality care indicator. 1
Duration of Therapy
A full 10-day course is essential to prevent rheumatic fever and ensure bacterial eradication, regardless of symptom improvement. 1, 4 Shorter courses with other antibiotics have not demonstrated equivalent efficacy to the standard 10-day penicillin regimen. 3, 5
Common Pitfalls
Do not use ampicillin as routine first-line therapy during pregnancy when treating suspected strep throat, as widespread antenatal ampicillin use has been associated with increased ampicillin-resistant early-onset neonatal sepsis with non-group B streptococcal organisms. 6 Penicillin G or penicillin V are preferred over ampicillin for this reason. 6
Asymptomatic carriers do not require treatment, as antimicrobial therapy is much less effective at eradicating group A streptococci from carriers than from patients with acute infections. 1