What is the treatment for streptococcal pharyngitis (strep throat)?

From the Guidelines

Strep throat should be treated with penicillin or amoxicillin as the first line of treatment, with a standard course of 10 days, to reduce morbidity, mortality, and improve quality of life. The dosage for adults is typically penicillin V 500 mg orally twice daily or amoxicillin 500 mg three times daily, while for children, the dosage is weight-based, usually 250-500 mg of amoxicillin twice daily 1. For those allergic to penicillin, alternatives include azithromycin or clindamycin, with specific dosages and durations 1. It is crucial to complete the full course of antibiotics even if symptoms improve before finishing, and to use over-the-counter pain relievers and gargling with warm salt water to manage symptoms while waiting for antibiotics to work.

Some key points to consider when treating strep throat include:

• The importance of completing the full course of antibiotics to prevent complications like rheumatic fever or kidney inflammation
• The use of penicillin or amoxicillin as the first line of treatment due to their proven efficacy, safety, and low cost
• The consideration of alternative antibiotics, such as azithromycin or clindamycin, for patients allergic to penicillin
• The use of over-the-counter pain relievers and gargling with warm salt water to manage symptoms while waiting for antibiotics to work
• The importance of staying hydrated with warm liquids and getting plenty of rest to aid in recovery.

According to the most recent and highest quality study, penicillin remains the treatment of choice for strep throat due to its proven efficacy and safety, and its narrow spectrum and low cost 1. Other antibiotics, such as cephalosporins and macrolides, may also be effective, but penicillin is generally considered the first line of treatment. It is essential to note that antimicrobial resistance has not been a significant issue in the treatment of group A streptococcal pharyngitis in the United States, and no clinical isolate of group A Streptococcus has been documented to be resistant to penicillin 1.

From the FDA Drug Label

In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum): otherwise the sequelae of streptococcal disease may occur.

NOTE: Penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever.

To treat strep throat, penicillin is the usual drug of choice, and therapy should be sufficient to eliminate the organism, with a minimum duration of ten days 2. Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy 3.

From the Research

Treatment Options for Strep Throat

• The primary treatment for strep throat is antibiotic therapy, with the goal of reducing the duration and severity of symptoms, as well as preventing complications 4, 5.
• Penicillin and amoxicillin are commonly recommended as first-line antibiotics, with a typical course lasting 10 days 4, 5.
• For patients with a non-anaphylactic allergy to penicillin, first-generation cephalosporins are recommended as an alternative 4, 5.
• Azithromycin and clarithromycin may not be effective due to significant resistance in some areas, and their use is not recommended as a first-line treatment 4, 6.

Duration of Antibiotic Treatment

• Traditional antibiotic regimens for strep throat last 10 days, but shorter courses of 5-7 days have been explored as a potential alternative 7, 8.
• Studies have shown that shorter courses of antibiotic treatment may be as effective as longer courses in achieving clinical cure and bacterial eradication, although the evidence is not uniform 7, 8.
• A systematic review and meta-analysis found that short-course antibiotic treatment was as effective as long-course treatment for early clinical cure, but subgroup analysis suggested that short-course penicillin may be less effective than long-course penicillin 8.

Additional Considerations

• Clinical decision rules, such as the modified Centor score, can be used to assess the risk of group A beta-hemolytic streptococcal infection and guide antibiotic treatment decisions 4, 5.
• Rapid antigen testing and throat culture can be used to confirm the diagnosis of strep throat, especially in cases where the clinical presentation is unclear 4, 5.
• Steroids are not recommended for symptomatic treatment of strep throat, and tonsillectomy is rarely recommended as a preventive measure 4, 5.