What are the recommended outpatient antibiotics for strep throat?

Outpatient Antibiotics for Strep Throat

First-Line Treatment

Penicillin V (250 mg three to four times daily or 500 mg twice daily for 10 days) or amoxicillin (50 mg/kg once daily, maximum 1000 mg, for 10 days in children) are the drugs of choice for treating strep throat. 1

• Penicillin V is recommended by the American Academy of Pediatrics as the drug of choice for adults and older children due to its narrow spectrum of activity, cost-effectiveness, and proven efficacy 1
• Amoxicillin is preferred for younger children because of better taste acceptance and availability as a suspension, with equal effectiveness to penicillin 1
• All oral antibiotics require a full 10-day course to achieve maximal pharyngeal eradication of Group A Streptococcus and prevent acute rheumatic fever 2, 1

Alternative for Compliance Concerns

• Intramuscular benzathine penicillin G (1.2 million units as a single injection) is preferred when compliance with 10-day oral therapy is unlikely, particularly in populations where rheumatic fever remains prevalent or medical care is episodic 1
• This single-injection regimen historically produced the highest cure rates and evolved as the gold standard because compliance is assured 3

Treatment for Penicillin-Allergic Patients

Non-Immediate/Non-Anaphylactic Penicillin Allergy

• First-generation cephalosporins are the preferred first-line alternatives for patients with non-immediate penicillin allergies 2, 4
• Cephalexin 500 mg twice daily for 10 days (adults) or 20 mg/kg per dose twice daily for 10 days (children) has strong, high-quality evidence for efficacy 2, 4
• Cefadroxil 1 gram once daily for 10 days (adults) or 30 mg/kg once daily for 10 days (children) is an alternative first-generation cephalosporin 2, 4

Immediate/Anaphylactic Penicillin Allergy

• Patients with immediate hypersensitivity (anaphylaxis, angioedema, or urticaria) should avoid all beta-lactams, including cephalosporins, due to up to 10% cross-reactivity risk 2, 4
• Clindamycin (7 mg/kg per dose three times daily, maximum 300 mg per dose, for 10 days) is the preferred alternative for immediate penicillin allergy 2, 1
• Clindamycin has strong, moderate-quality evidence and demonstrates high efficacy in eradicating streptococci, even in chronic carriers 2
• Azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days) is an acceptable alternative with a shorter course due to prolonged tissue half-life 2
• Clarithromycin (7.5 mg/kg per dose twice daily, maximum 250 mg per dose, for 10 days) is another macrolide option 2

Critical Considerations and Pitfalls

Macrolide Resistance

• Be aware of local macrolide resistance patterns before prescribing azithromycin or clarithromycin, as resistance varies geographically and is approximately 5-8% in the United States 2
• There is significant resistance to azithromycin and clarithromycin in some parts of the United States 5

Treatment Duration

• Do not prescribe shorter courses than recommended (except for azithromycin's 5-day regimen) to prevent treatment failure and acute rheumatic fever 4
• Azithromycin is the only exception requiring only 5 days due to its unique pharmacokinetics 2, 1

Common Mistakes to Avoid

• Do not use azithromycin or other macrolides as first-line when penicillin can be used 1
• Do not assume all penicillin-allergic patients cannot receive cephalosporins—only those with immediate/anaphylactic reactions should avoid them 2, 4
• Do not use trimethoprim-sulfamethoxazole (Bactrim) for strep throat due to high resistance rates (50%) and lack of effectiveness against Group A Streptococcus 2

Adjunctive Therapy

• Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever 2
• Avoid aspirin in children due to risk of Reye syndrome 2
• Corticosteroids are not recommended as adjunctive therapy 2

Special Populations

• Chronic carriers generally do not require antimicrobial therapy, as they are unlikely to spread infection or develop complications 2, 4
• For patients with recurrent streptococcal pharyngitis, clindamycin may be particularly effective due to its ability to eradicate the organism in chronic carriers 2
• Routine post-treatment throat cultures are not recommended for asymptomatic patients who have completed therapy, except in special circumstances such as patients with a history of rheumatic fever 4