What is the recommended treatment for strep throat?

Treatment for Strep Throat

Penicillin V or amoxicillin for 10 days is the first-line treatment for strep throat due to proven efficacy, narrow spectrum, safety, and low cost, with no documented penicillin resistance in Group A streptococci. 1, 2

First-Line Treatment for Non-Allergic Patients

Penicillin V remains the gold standard for treating Group A streptococcal pharyngitis, with the following dosing regimens 1:

• Adults and adolescents: 250 mg four times daily OR 500 mg twice daily for 10 days 1
• Children: 250 mg two or three times daily for 10 days 1
• Twice-daily dosing is as effective as more frequent dosing and may improve compliance 3

Amoxicillin is preferred for young children due to better taste acceptance and palatability of the suspension 1, 2:

• Dosing: 50 mg/kg once daily (maximum 1000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 4
• Once-daily amoxicillin is as effective as three-times-daily penicillin V and may enhance adherence 1, 5
• Studies show amoxicillin at 40 mg/kg/day achieves superior bacteriologic cure rates (79.3%) compared to lower-dose penicillin V (54.5%) 6

Intramuscular benzathine penicillin G is the preferred option for patients unlikely to complete oral therapy 1:

• Dosing: Less than 60 lbs (27 kg): 600,000 units; 60 lbs or greater: 1,200,000 units as a single dose 1

Treatment for Penicillin-Allergic Patients

Non-Immediate (Non-Anaphylactic) Penicillin Allergy

First-generation cephalosporins are the preferred first-line alternatives for patients without immediate hypersensitivity reactions 1, 7, 2:

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 1, 7
• Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days 1, 7
• Cross-reactivity risk with penicillin is less than 3-10% 1, 8, 7

Immediate/Anaphylactic Penicillin Allergy

Avoid all beta-lactam antibiotics (including cephalosporins) in patients with immediate hypersensitivity due to up to 10% cross-reactivity risk 1, 7

Clindamycin is the preferred alternative for immediate penicillin allergy 1, 7, 2:

• Dosing: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1, 7
• Resistance rate is only approximately 1% in the United States 1, 7
• Particularly effective for chronic carriers and difficult-to-eradicate infections 8, 7

Macrolides are acceptable alternatives but have geographic resistance concerns 1, 7, 2:

• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days only 1, 7, 2
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 1, 7
• Erythromycin: 20-40 mg/kg/day divided 2-3 times daily for 10 days 1, 7
• Macrolide resistance is approximately 5-8% in the United States but varies geographically and temporally 1, 7, 2

Critical Treatment Duration Requirements

A full 10-day course is essential for all antibiotics except azithromycin to achieve maximal pharyngeal eradication and prevent acute rheumatic fever 1, 2, 4:

• Therapy can be safely delayed up to 9 days after symptom onset and still prevent rheumatic fever 7
• Azithromycin requires only 5 days due to its prolonged tissue half-life 1, 7, 2
• Shortening courses by even a few days results in appreciable increases in treatment failure rates 7

Adjunctive Therapy

Symptomatic relief should be provided with analgesics or antipyretics 1, 7:

• Acetaminophen or NSAIDs (ibuprofen) for moderate to severe symptoms or high fever 1, 7
• Never use aspirin in children due to Reye syndrome risk 1, 7
• Corticosteroids are not recommended as adjunctive therapy 1, 7

Common Pitfalls to Avoid

Do not use amoxicillin or ampicillin in patients with concurrent infectious mononucleosis due to high risk of severe rash; use first-generation cephalosporin or macrolide instead 8, 2

Do not prescribe shorter courses than recommended (except azithromycin's 5-day regimen) as this leads to treatment failure and complications 7, 2

Do not assume all penicillin-allergic patients cannot receive cephalosporins—only those with immediate/anaphylactic reactions should avoid them 1, 7, 2

Avoid these antibiotics entirely for strep throat 1, 2:

• Tetracyclines (high resistance rates)
• Sulfonamides and trimethoprim-sulfamethoxazole (do not eradicate Group A streptococci; ~50% resistance)
• Older fluoroquinolones like ciprofloxacin (limited activity against Group A streptococci)

Post-Treatment Considerations

Patients become non-contagious after 24 hours of appropriate antibiotic therapy 8, 2

Routine follow-up throat cultures are not recommended for asymptomatic patients who completed therapy 1, 8, 7, 2

Testing household contacts is not routinely recommended unless there are special circumstances such as recurrent infections or history of rheumatic fever 1