What is the management of streptococcal (Strep) pharyngitis?

From the Guidelines

For strep pharyngitis, the recommended first-line treatment is penicillin V potassium (phenoxymethylpenicillin) 250 mg orally twice daily for 10 days for children and 500 mg orally twice daily for 10 days for adolescents and adults, as supported by the most recent guidelines 1. This recommendation is based on the fact that penicillin V is effective in eradicating Group A Streptococcus bacteria, reducing symptom duration, and preventing complications like rheumatic fever 1. Some key points to consider when treating strep pharyngitis include:

• Completing the full course of antibiotics is crucial even if symptoms resolve earlier to prevent complications like rheumatic fever 1.
• For patients with penicillin allergy, alternatives include cephalexin 20 mg/kg/dose twice daily (maximum 500 mg/dose) for 10 days, or in cases of severe penicillin allergy, azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days 1.
• Patients should be advised to rest, maintain hydration, use salt water gargles, and take acetaminophen or ibuprofen for pain and fever.
• Antibiotics are effective because they eliminate Group A Streptococcus bacteria, reducing symptom duration by about 16 hours, decreasing contagiousness, and preventing complications 1.
• Patients can generally return to school or work 24 hours after starting antibiotics when they are no longer contagious. It's worth noting that the most recent study 1 provides the strongest evidence for the recommended treatment, and its findings should be prioritized in clinical decision-making.

From the FDA Drug Label

Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy Azithromycin is often effective in the eradication of susceptible strains of Streptococcus pyogenes from the nasopharynx Because some strains are resistant to azithromycin, susceptibility tests should be performed when patients are treated with azithromycin. Data establishing efficacy of azithromycin in subsequent prevention of rheumatic fever are not available.

MDM for strep pharyngitis: Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy for the treatment of pharyngitis/tonsillitis caused by Streptococcus pyogenes. However, susceptibility tests should be performed to ensure the strain is susceptible to azithromycin, and it is not recommended for the prevention of rheumatic fever 2.

• Key points:
  • Azithromycin is effective in eradicating susceptible strains of Streptococcus pyogenes.
  • Susceptibility tests should be performed before treatment.
  • Not recommended for prevention of rheumatic fever.
  • Can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy.

From the Research

Diagnosis of Streptococcal Pharyngitis

• The diagnosis of streptococcal pharyngitis can be made using clinical decision rules, such as the modified Centor or FeverPAIN score, followed by rapid antigen testing if a diagnosis is unclear 3, 4.
• A throat culture is recommended in children and adolescents after a negative rapid antigen test result 3.
• The strongest independent predictors of GABHS pharyngitis are patient age of five to 15 years, absence of cough, tender anterior cervical adenopathy, tonsillar exudates, and fever 4.

Treatment of Streptococcal Pharyngitis

• First-line treatment for GABHS pharyngitis includes a 10-day course of penicillin or amoxicillin 3, 4.
• Patients allergic to penicillin can be treated with first-generation cephalosporins, clindamycin, or macrolide antibiotics 3, 4.
• Short-course antibiotic treatment may be as effective as long-course antibiotic treatment for early clinical cure and bacteriological eradication, but the benefits and harms of using short-course treatment should be carefully considered 5.
• Azithromycin may be an alternative treatment for streptococcal pharyngitis in adult outpatients, but it is not recommended as a first-line treatment due to resistance concerns 6, 3.

Management of Streptococcal Pharyngitis

• Nonsteroidal anti-inflammatory drugs and medicated throat lozenges can be used to treat fever and pain associated with GABHS pharyngitis 4.
• Corticosteroids are not recommended for routine use in the treatment of streptococcal pharyngitis due to their limited benefits 3, 4.
• Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment should be reevaluated 3.