What is the recommended treatment for pediatric Group A Streptococcal (GAS) infections?

From the Guidelines

The recommended treatment for pediatric Group A Streptococcal (GAS) infections is penicillin or amoxicillin for 10 days.

Treatment Options

• For individuals without penicillin allergy, the following options are available:
  • Penicillin V, oral: 250 mg twice daily or 3 times daily for children, and 250 mg 4 times daily or 500 mg twice daily for adolescents and adults, for 10 days 1
  • Amoxicillin, oral: 50 mg/kg once daily (max = 1000 mg) or 25 mg/kg (max = 500 mg) twice daily, for 10 days 1
  • Benzathine penicillin G, intramuscular: 600,000 U for children <27 kg and 1,200,000 U for children ≥27 kg, as a single dose 1
• For individuals with penicillin allergy, the following options are available:
  • Cephalexin, oral: 20 mg/kg/dose twice daily (max = 500 mg/dose), for 10 days 1
  • Clindamycin, oral: 7 mg/kg/dose 3 times daily (max = 300 mg/dose), for 10 days 1
  • Azithromycin, oral: 12 mg/kg once daily (max = 500 mg), for 5 days 1

Important Considerations

• Antimicrobial therapy should be initiated as soon as possible after diagnosis is confirmed by culture or rapid antigen detection test (RADT) 1
• Early initiation of antimicrobial therapy results in faster resolution of signs and symptoms 1
• Therapy can be safely postponed for up to 9 days after the onset of symptoms and still prevent the occurrence of acute rheumatic fever 1
• Penicillin remains the treatment of choice due to its proven efficacy, safety, narrow spectrum, and low cost 1

From the Research

Recommended Treatment for Pediatric Group A Streptococcal (GAS) Infections

The recommended treatment for pediatric Group A Streptococcal (GAS) infections is primarily focused on preventing complications and reducing symptom duration.

• The first-line therapy for streptococcal pharyngitis is a 10-day course of penicillin V, usually given 2 or 3 times per day 2.
• Alternative treatments include other penicillins, macrolides, and cephalosporins, with cephalosporins potentially offering higher bacteriologic eradication rates than penicillin V 2.
• A 5-day dosing schedule of third-generation cephalosporins, such as cefdinir and cefpodoxime proxetil, may increase adherence to the full course of therapy and is preferred by children due to its palatability 2.
• However, recent studies suggest that antibiotics may have a limited impact on the duration of fever and the intensity of pain in children with streptococcal pharyngitis, supporting a more judicious approach to antibiotic prescriptions 3.
• Amoxicillin or penicillin are recommended for children who are likely to have GAS pharyngitis based on history or physical examination, with a throat swab and positive test results 4.

Considerations for Treatment

• The use of antibiotics in treating GAS pharyngitis is debated, with some studies suggesting that the benefits of antibiotics in preventing complications are limited 3.
• The primary justification for antibiotic use remains the reduction of symptoms, but the results of a randomized, multicenter, double-blind, non-inferiority trial suggest that a placebo may be non-inferior to amoxicillin in reducing fever duration 3.
• The optimal duration of antibiotic therapy is still uncertain, especially given the current peak in streptococcal infections 5.
• In severe cases of GAS infection, such as sepsis, IVIG and clindamycin may be used, but their use is not universally recommended 6.