What is the recommended treatment for strep throat in a pregnant woman?

Treatment of Strep Throat in Pregnant Women

Penicillin V (500 mg orally twice daily for 10 days) or amoxicillin (500 mg orally three times daily for 10 days) are the first-line treatments for strep throat in pregnant women, offering proven safety for both mother and fetus with excellent efficacy against Group A Streptococcus. 1

First-Line Antibiotic Therapy

• Penicillin V 500 mg orally twice daily for 10 days is the preferred treatment, as it has a narrow spectrum of activity that minimizes disruption of normal flora and reduces antibiotic resistance 1

• Amoxicillin 500 mg orally three times daily for 10 days is an equally acceptable alternative, particularly for patients who prefer less frequent dosing or have better tolerability with amoxicillin 1, 2

• Both penicillin and cephalosporin antibiotics are considered the safest classes during pregnancy, with no documented fetal harm 1

• Amoxicillin should be taken at the start of a meal to minimize gastrointestinal intolerance 2

Critical Importance of Full Treatment Course

• A complete 10-day course is essential to prevent rheumatic fever and ensure bacterial eradication, regardless of symptom improvement 1, 2

• Treatment should be continued for at least 10 days for any infection caused by Streptococcus pyogenes to prevent acute rheumatic fever 2

• Shorter courses of penicillin (≤5 days) are significantly less effective, with reduced clinical cure rates (OR 0.43) and bacteriological eradication (OR 0.34) compared to standard 10-day therapy 3

Management for Penicillin-Allergic Patients

For Non-Severe Penicillin Allergy (No History of Anaphylaxis)

• Cefazolin is the preferred alternative for pregnant women without high-risk allergy symptoms 1

• First-generation cephalosporins like cefazolin have an excellent safety profile in pregnancy and maintain efficacy against Group A Streptococcus 1

For High-Risk Penicillin Allergy (History of Anaphylaxis, Angioedema, or Urticaria)

• Clindamycin 300 mg orally four times daily for 10 days should be used if susceptibility testing confirms the streptococcal isolate is susceptible to clindamycin 1

• Erythromycin is an alternative option, though it has more gastrointestinal side effects; the typical dose is 500 mg orally four times daily for 10 days 4, 5

• Approximately 10% of persons with penicillin allergy also have immediate hypersensitivity reactions to cephalosporins, making risk stratification essential 6

Antibiotics to Avoid During Pregnancy

• Tetracyclines (including doxycycline), aminoglycosides, trimethoprim-sulfamethoxazole, and fluoroquinolones must be avoided due to potential fetal risks 1

Diagnostic Confirmation Required

• Treatment should be based on positive throat culture or rapid antigen detection testing (RADT) for Group A Streptococcus 1

• Withholding antibiotics in patients with negative microbiological tests is a quality care indicator to prevent unnecessary antibiotic exposure 1

• Asymptomatic carriers do not require treatment, as antimicrobial therapy is much less effective at eradicating Group A Streptococcus from carriers than from patients with acute infections 1

Important Clinical Pitfalls to Avoid

• Do not treat based on symptoms alone without microbiological confirmation, as this leads to unnecessary antibiotic use and potential harm 1

• Do not allow premature discontinuation of therapy even if symptoms resolve early, as this increases treatment failure and rheumatic fever risk 1, 3

• Do not use macrolides or cephalosporins as first-line therapy in non-allergic patients, as these are "Highest Priority Critically Important Antimicrobials" and should be reserved to minimize resistance 3

Special Consideration for Penicillin Allergy Verification

• Many reported penicillin allergies are not true IgE-mediated reactions, and pregnant women with reported penicillin allergy should undergo verification of their allergy history 6

• Penicillin allergy testing in pregnancy has been demonstrated to be safe, with 95% of tested pregnant patients having their penicillin allergy label safely removed 7

• Patients who undergo allergy evaluation have significantly increased use of first-line beta-lactam antibiotics (OR 18.0) and reduced use of broad-spectrum alternatives like vancomycin (OR 0.07) and clindamycin (OR 0.17) 7