What is the recommended treatment for strep throat?

Treatment for Strep Throat

Penicillin V or amoxicillin for 10 days is the definitive first-line treatment for strep throat, with penicillin remaining the gold standard due to its proven efficacy, narrow spectrum, safety profile, and the fact that penicillin-resistant Group A Streptococcus has never been documented anywhere in the world. 1, 2

First-Line Antibiotic Therapy

Penicillin V (Oral)

• Children: 250 mg twice or three times daily for 10 days 1
• Adolescents and adults: 250 mg four times daily OR 500 mg twice daily for 10 days 1
• The twice-daily 500 mg regimen is equally effective as more frequent dosing and may improve adherence 3, 4

Amoxicillin (Oral)

• Standard dosing: 50 mg/kg once daily (maximum 1,000 mg) for 10 days 1
• Alternative: 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
• Once-daily dosing enhances adherence while maintaining equal efficacy to penicillin V 1, 2
• Often preferred in young children due to better palatability of the suspension 1

Intramuscular Benzathine Penicillin G

• Patients < 60 lb (27 kg): 600,000 units as a single dose 1
• Patients ≥ 60 lb: 1,200,000 units as a single dose 1
• Preferred when: Compliance with 10-day oral therapy is unlikely, in populations where rheumatic fever remains prevalent, or in settings with episodic medical care 1, 5

Treatment for Penicillin-Allergic Patients

Non-Anaphylactic Penicillin Allergy

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 1
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1
• Critical caveat: Avoid all cephalosporins in patients with immediate hypersensitivity or anaphylactic reactions to penicillin 1

Immediate Hypersensitivity to Penicillin

• Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 6
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 1
• Important limitation: Geographic and temporal variation in macrolide resistance exists, making these second-line options 1

Critical Treatment Principles

Duration of Therapy

• 10 days is mandatory for most oral antibiotics to achieve maximal pharyngeal eradication of Group A Streptococcus 1, 7
• Azithromycin is the only exception, requiring only 5 days due to prolonged tissue half-life 1
• Shorter courses risk inadequate eradication and potential non-suppurative sequelae 7

When NOT to Use Broad-Spectrum Antibiotics

• Amoxicillin-clavulanate (Augmentin) should NOT be used as first-line therapy for uncomplicated strep throat 2
• Reserve amoxicillin-clavulanate only for chronic GAS carriers: 40 mg amoxicillin/kg/day in three divided doses (maximum 2,000 mg/day) for 10 days 2
• Broad-spectrum agents increase costs, promote antimicrobial resistance, and cause more gastrointestinal side effects without additional clinical benefit 2

Adjunctive Symptomatic Management

Recommended

• Analgesics/antipyretics: Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1

NOT Recommended

• Aspirin in children: Risk of Reye syndrome 1
• Corticosteroids: Not recommended as adjunctive therapy for routine strep throat 1
• Corticosteroids may be considered only in adults with severe presentations (3-4 Centor criteria), but this is not standard practice 1

Follow-Up and Testing Considerations

Post-Treatment Testing

• Routine follow-up cultures or rapid tests are NOT recommended after treatment 1
• May be considered in special circumstances: personal/family history of rheumatic fever, community outbreaks, or persistent symptoms 1

Household Contacts

• Do NOT routinely test or treat asymptomatic household contacts 1
• Antibiotic prophylaxis has not been shown to reduce secondary illness effectively 1
• Exception: Consider during outbreaks of rheumatic fever, post-streptococcal glomerulonephritis, or invasive GAS infections 1

Common Pitfalls to Avoid

• Incomplete treatment course: Patients often feel better within 24-48 hours but must complete the full 10-day course to prevent sequelae and eradication failure 7, 5
• Using once-daily penicillin V: Once-daily dosing of penicillin V (1000 mg) results in higher rates of persistent positive cultures and recurrence compared to twice or four times daily dosing 3
• Treating viral pharyngitis: Do not prescribe antibiotics when clinical features suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers) 1
• Overuse in low-risk patients: Antibiotics should not be used to prevent rheumatic fever or suppurative complications in low-risk patients with 0-2 Centor criteria 1

Clinical Efficacy Expectations

• Symptom resolution: Most patients experience clinical improvement within 24-48 hours of initiating appropriate antibiotic therapy 1, 5
• Bacteriologic cure rates: Penicillin achieves 87-96% eradication rates, while clarithromycin and azithromycin achieve 91-95% 8, 9
• Self-limited disease: Strep throat is ultimately self-limited, but early treatment reduces symptom duration, decreases suppurative complications, and limits transmission 1, 5