Treatment for Strep Throat
Penicillin V (250 mg three to four times daily or 500 mg twice daily for 10 days) is the first-line treatment for strep throat in adults and older children, while amoxicillin (50 mg/kg once daily, maximum 1000 mg, for 10 days) is preferred for younger children due to better taste and suspension availability. 1, 2
First-Line Treatment Algorithm
For Non-Allergic Patients
Penicillin remains the drug of choice because of its proven efficacy, narrow spectrum, low cost, and established ability to prevent acute rheumatic fever—the primary goal of treatment. 3, 1, 2
- Adults and older children: Penicillin V 250 mg three to four times daily OR 500 mg twice daily for 10 days 1, 2
- Younger children: Amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days 1, 2
- When compliance is questionable: Intramuscular benzathine penicillin G 1.2 million units as a single injection 1
Critical: A full 10-day course is mandatory to achieve maximal pharyngeal eradication and prevent acute rheumatic fever. 1, 2 Shorter courses of penicillin are less effective for both clinical cure and bacterial eradication. 4
When to Treat vs. Observe
Use the Centor criteria to guide treatment decisions: 3
- 0-2 Centor criteria: Do NOT use antibiotics—symptoms resolve without treatment and complications are rare 3
- 3-4 Centor criteria: Consider antibiotics after discussing modest benefits versus side effects, resistance concerns, and costs 3
The guideline explicitly states that preventing suppurative complications (quinsy, otitis media, lymphadenitis) is NOT a specific indication for antibiotics, and most cases do not require treatment to prevent these outcomes. 3
Treatment for Penicillin-Allergic Patients
Non-Immediate (Non-Anaphylactic) Penicillin Allergy
First-generation cephalosporins are the preferred alternative with strong, high-quality evidence supporting their efficacy. 5, 1, 2
- Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg/dose) for 10 days 5
- Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days 5
Important caveat: Up to 10% of patients with immediate hypersensitivity to penicillin have cross-reactivity with first-generation cephalosporins, so these should be avoided in anaphylactic reactions. 5
Immediate/Anaphylactic Penicillin Allergy
Clindamycin is the preferred choice with strong, moderate-quality evidence and only ~1% resistance among Group A Streptococcus in the United States. 5, 1, 2
Alternative macrolides (use with caution due to resistance):
- Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days only 5, 2, 6
- Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg/dose) for 10 days 5
- Erythromycin: 20-40 mg/kg/day divided 2-3 times daily for 10 days 5, 7
Critical resistance consideration: Macrolide resistance is approximately 5-8% in the United States but varies geographically. 5, 2 Clindamycin resistance remains very low at ~1%. 5
Adjunctive Symptomatic Treatment
For pain and fever relief: 3, 5
- Ibuprofen or acetaminophen are recommended for symptom relief 3
- Avoid aspirin in children due to Reye syndrome risk 5
Corticosteroids are NOT routinely recommended except possibly in adults with severe presentations (3-4 Centor criteria). 3, 5
Common Pitfalls to Avoid
Do not use azithromycin or macrolides as first-line when penicillin can be used—reserve these for true penicillin allergy. 5, 1
Do not prescribe shorter courses than recommended (except azithromycin's 5-day regimen)—this leads to treatment failure and does not prevent rheumatic fever. 5, 2, 4
Do not assume all penicillin-allergic patients cannot receive cephalosporins—only those with immediate/anaphylactic reactions should avoid them due to 10% cross-reactivity. 5
Do not use trimethoprim-sulfamethoxazole as resistance rates are approximately 50%. 5, 2
Do not use amoxicillin in adolescents with possible infectious mononucleosis due to rash risk—use first-generation cephalosporin or macrolide instead. 2
Do not treat asymptomatic carriers—they are at low risk of transmission and complications. 3, 5
Post-Treatment Considerations
Patients become non-contagious after 24 hours of appropriate antibiotic therapy. 2
Routine follow-up cultures are NOT recommended for asymptomatic patients who completed therapy—only consider in special circumstances like history of rheumatic fever. 3, 5
Zinc gluconate, herbal treatments, and acupuncture are NOT recommended due to inconsistent or insufficient evidence. 3