What are the alternative treatments for strep throat?

Alternative Treatments for Strep Throat

For patients who cannot use penicillin, first-generation cephalosporins (such as cephalexin or cefadroxil) are the preferred first-line alternatives for those with non-immediate penicillin allergies, while clindamycin or azithromycin should be used for patients with immediate/anaphylactic reactions. 1, 2

Treatment Algorithm Based on Penicillin Allergy Type

Non-Immediate (Non-Anaphylactic) Penicillin Allergy

First-generation cephalosporins are the preferred choice with strong, high-quality evidence supporting their efficacy in patients without immediate hypersensitivity to β-lactam antibiotics. 1, 2

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg/dose) for 10 days 2
• Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days 2

These agents demonstrate superior bacteriologic eradication rates compared to penicillin and offer convenient dosing. 2

Immediate/Anaphylactic Penicillin Allergy

Patients with immediate hypersensitivity must avoid all beta-lactam antibiotics, including cephalosporins, due to up to 10% cross-reactivity risk. 2

Clindamycin (Preferred Option)

• Dosing: 7 mg/kg per dose three times daily (maximum 300 mg/dose) for 10 days 2
• Evidence: Strong, moderate-quality evidence with high efficacy in eradicating streptococci, even in chronic carriers 2
• Resistance: Approximately 1% resistance rate in the United States 2

Azithromycin (Alternative Option)

• Dosing: 12 mg/kg once daily (maximum 500 mg) for 5 days 2, 3
• Evidence: Strong, moderate-quality evidence; FDA-approved as alternative to first-line therapy 3
• Unique feature: Only requires 5-day course due to prolonged tissue half-life 2
• Important caveat: Data establishing efficacy in preventing rheumatic fever are not available 3
• Resistance concern: Macrolide resistance among Group A Streptococcus is approximately 5-8% in the United States 2

Clarithromycin (Alternative Option)

• Dosing: 7.5 mg/kg per dose twice daily (maximum 250 mg/dose) for 10 days 2
• Evidence: Strong, moderate-quality evidence 2

Erythromycin (Less Preferred)

• Dosing: 20-40 mg/kg/day divided 2-3 times daily for 10 days 2
• Limitation: Less preferred due to significant gastrointestinal side effects and need for multiple daily doses 4

Critical Treatment Duration Requirements

All antibiotics except azithromycin require a full 10-day course to achieve maximal pharyngeal eradication of Group A Streptococcus and prevent acute rheumatic fever. 1, 2 Shortening the course by even a few days results in appreciable increases in treatment failure rates. 1

Key Clinical Considerations and Pitfalls

Cross-Reactivity Warning

Do not prescribe cephalosporins to patients with immediate/anaphylactic penicillin reactions. The 10% cross-reactivity risk makes this potentially dangerous. 2 Only patients with non-immediate reactions (e.g., delayed rash) can safely receive cephalosporins. 2

Macrolide Resistance

Be aware of local resistance patterns before prescribing azithromycin or clarithromycin, as macrolide resistance varies geographically and temporally. 2 In areas with high macrolide resistance, clindamycin becomes the preferred option for severe penicillin allergy. 2

Susceptibility Testing for Azithromycin

Because some strains are resistant to azithromycin, susceptibility tests should be performed when patients are treated with this agent. 3

Treatment Goals

The primary goal of antibiotic therapy is not only symptomatic improvement but also prevention of acute rheumatic fever, which requires adequate bacterial eradication. 1 This is why completing the full course is essential.

Post-Treatment Testing

Routine follow-up throat cultures or rapid antigen detection tests are not recommended for asymptomatic patients who have completed therapy. 1, 2 Testing should only be considered in special circumstances, such as patients with a history of rheumatic fever. 2

Chronic Carriers

Chronic carriers (positive throat culture without symptoms) generally do not require antimicrobial therapy, as they are unlikely to spread infection or develop complications. 2 However, if treatment is needed for chronic carriers, clindamycin demonstrates particularly high efficacy. 2

Adjunctive Symptomatic 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

When to Consider Alternative Regimens

For patients with recurrent streptococcal pharyngitis after initial treatment, consider whether they are experiencing multiple true infections versus chronic carriage with viral superinfection. 2 If retreatment is needed and compliance with oral therapy is questionable, intramuscular benzathine penicillin G should be considered. 1