From the Guidelines
For the treatment of pharyngitis, particularly Group A Streptococcus (strep throat), the first-line antibiotics recommended are penicillin or amoxicillin for 10 days, as they have a narrow spectrum of activity, infrequent adverse reactions, and modest cost, as supported by the Infectious Diseases Society of America guidelines 1. When considering the treatment for pharyngitis, it's crucial to differentiate between viral and bacterial causes, with most cases being viral and requiring only supportive care. However, for bacterial pharyngitis, especially Group A Streptococcus, antibiotics are essential. The choice of antibiotic should be based on the patient's allergy history, with penicillin or amoxicillin being the preferred choice for non-allergic patients. For patients allergic to penicillin, alternatives such as cephalexin (for those not anaphylactically sensitive), clindamycin, or azithromycin can be considered, as suggested by both the Infectious Diseases Society of America guidelines 1 and more recent recommendations on essential medicines 1. It's also important to note that diagnosis should ideally be confirmed with rapid strep testing or throat culture before initiating antibiotic therapy to avoid unnecessary antibiotic use. Completing the full course of antibiotics, even after symptoms improve, is crucial to prevent complications and reduce transmission. Given the most recent and highest quality evidence, the recommendation for the treatment of pharyngitis, especially when caused by Group A Streptococcus, prioritizes penicillin or amoxicillin as the first-line treatment, emphasizing the importance of proper diagnosis and completion of the antibiotic course, as highlighted in the guidelines 1 and supported by more recent considerations on antibiotic treatment 1.
From the FDA Drug Label
In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS): Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14Day 30 Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%) Penicillin V242/332 (73%)206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%) Penicillin V284/338 (84%)241/325 (74%)
Azithromycin is effective for the treatment of pharyngitis due to Group A β-hemolytic streptococci, with a clinical success rate of 98% at Day 14 and 94% at Day 30, and bacteriologic eradication rates of 95% at Day 14 and 77% at Day 30 2.
From the Research
Pharyngitis Treatment
- The treatment of pharyngitis depends on the causative agent, with group A streptococcus (Streptococcus pyogenes) being the most important bacterial cause 3.
- For group A streptococcal pharyngitis, antimicrobial treatment is effective, with penicillin, erythromycin, and peroral first-generation cephalosporins being documented as effective options 3.
- The goals of treatment include prevention of suppurative and nonsuppurative complications, abatement of clinical signs and symptoms, reduction of bacterial transmission, and minimization of antimicrobial adverse effects 4.
Antibiotic Selection
- Oral penicillin remains the drug of choice for most clinical situations, although cephalosporins and amoxicillin-clavulanate potassium may provide superior bacteriologic and clinical cure rates 4.
- Alternative treatments must be used in patients with penicillin allergy, compliance issues, or penicillin treatment failure, with options including amoxicillin-clavulanate potassium, cephalosporins, or macrolides 4.
- For patients who do not respond to initial treatment, an antimicrobial that is not inactivated by penicillinase-producing organisms should be used, such as amoxicillin-clavulanate potassium, a cephalosporin, or a macrolide 4.
Current Recommendations
- Current recommendations for the treatment of group A β-hemolytic streptococcal pharyngitis include oral penicillin V and amoxicillin as the drugs of choice, with oral cephalosporin being an acceptable alternative for patients with a non-anaphylactic allergy to penicillin 5.
- For patients with a history of immediate, anaphylactic-type hypersensitivity to penicillin, oral clindamycin, clarithromycin, and azithromycin are acceptable alternatives 5.
- Early diagnosis and antimicrobial treatment are recommended to prevent suppurative complications, non-suppurative complications, and to reduce the severity of symptoms, shorten the duration of the illness, and reduce disease transmission 5.