What is the recommended treatment for strep throat?

Treatment of Streptococcal Pharyngitis

First-Line Antibiotic Therapy

Penicillin or amoxicillin for 10 days remains the treatment of choice for Group A streptococcal pharyngitis due to proven efficacy, narrow spectrum, safety, and low cost. 1, 2

Penicillin V Dosing

• Children: 250 mg two or three times daily for 10 days 2
• Adolescents and adults: 250 mg four times daily OR 500 mg twice daily for 10 days 1, 2
• The twice-daily 500 mg regimen is preferred over once-daily dosing, as once-daily penicillin shows higher rates of persistent positive cultures (10.4% vs 0%) and recurrent infections (23% vs 8%) 3

Amoxicillin Dosing (Often Preferred in Children)

• 50 mg/kg once daily (maximum 1000 mg) for 10 days 1, 2, 4
• Alternative: 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 4
• Amoxicillin is chosen over penicillin V in young children due to better palatability and suspension availability 1
• Higher-dose amoxicillin (40 mg/kg/day) demonstrates superior clinical cure (87.9% vs 70.9%) and bacteriologic cure (79.3% vs 54.5%) compared to standard-dose penicillin V 5

Intramuscular Option for Compliance Concerns

• Benzathine penicillin G: 600,000 units (if <27 kg) or 1,200,000 units (if ≥27 kg) as single intramuscular dose 6, 2
• Reserve for patients unlikely to complete 10-day oral course 6

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Treatment for Penicillin-Allergic Patients

Non-Anaphylactic Penicillin Allergy

First-generation cephalosporins for 10 days are recommended 1, 7, 2:

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) 7, 6
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) 7, 6
• Do NOT use in patients with immediate hypersensitivity/anaphylaxis to penicillin 6, 2

Anaphylactic or Immediate-Type Penicillin Allergy

Clindamycin is the preferred alternative 1, 7, 2:

• 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 7, 2

Alternative Macrolides (Use with Caution)

• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 7
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 7
• Critical caveat: Macrolide resistance varies geographically and can be as high as 26% 8. In areas with high clarithromycin resistance, bacteriologic failure rates reach 81-86% for resistant strains 8. Avoid macrolides where resistance rates are elevated 7, 8

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Treatment Duration: Why 10 Days Matters

The full 10-day course is essential to achieve maximal pharyngeal eradication and prevent acute rheumatic fever 1, 2, 4:

• Treatment must continue at least 10 days for any Group A streptococcal infection to prevent rheumatic fever 1, 4
• Azithromycin is the only exception, requiring just 5 days due to prolonged tissue half-life 1, 6
• While some research suggests 5-7 day courses may have similar outcomes 9, guidelines consistently recommend 10 days for most antibiotics 1, 2
• Shorter cephalosporin courses (4-5 days) show modest superiority over 10-day penicillin in meta-analyses, but differences are not clinically significant 1

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Management of Treatment Failures

Approach to Persistent or Recurrent Infection

• Confirm each episode with rapid antigen detection test (RADT) or throat culture 7
• Distinguish between true recurrent infection versus chronic carrier state with superimposed viral pharyngitis 7, 2
• For documented treatment failure with adequate compliance: Retreat with same regimen 2
• For questionable compliance: Use intramuscular benzathine penicillin G 2

Chronic Carriers or Multiple Failures

Clindamycin is highly effective for eradicating carrier states 6, 2:

• 20-30 mg/kg per day in three divided doses (maximum 300 mg per dose) for 10 days 6, 2

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Adjunctive Symptomatic Management

Analgesics and antipyretics are recommended for moderate to severe symptoms or high fever 7, 2:

• Acetaminophen or NSAIDs are appropriate 7, 2
• Avoid aspirin in children due to Reye syndrome risk 7, 2
• Corticosteroids are NOT recommended 7, 2

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Critical Pitfalls to Avoid

• Do NOT routinely test or treat asymptomatic household contacts 1—streptococcal pharyngitis is self-limited, and prophylaxis shows minimal benefit with potential for adverse effects and resistance 1
• Do NOT perform routine post-treatment cultures unless in special circumstances 1
• Avoid overdiagnosis of viral pharyngitis as bacterial infection 7—use clinical criteria (Centor score) and confirmatory testing 1, 7
• Do NOT use macrolides as first-line in areas with known high resistance rates 7, 8
• Avoid once-daily penicillin dosing—twice-daily or more frequent dosing is superior 3
• Do NOT recommend tonsillectomy solely to reduce GAS pharyngitis frequency 7