What is the appropriate treatment for a 12-year-old child with recurrent Streptococcal (Group A beta-hemolytic streptococcal) pharyngitis?

From the Guidelines

For a 12-year-old child with recurrent streptococcal pharyngitis, the most appropriate treatment is typically a course of antibiotics, with penicillin being the first-line therapy, specifically Amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days, as recommended by the most recent and highest quality study 1. This recommendation is based on the strongest and most recent evidence, which prioritizes morbidity, mortality, and quality of life as the outcome. The use of Amoxicillin is due to its better taste and improved compliance, making it a more effective treatment option for children. For penicillin-allergic patients, alternatives include cephalexin 25-50 mg/kg/day divided twice daily for 10 days (if non-anaphylactic allergy) or clindamycin 20-30 mg/kg/day divided three times daily for 10 days (if severe penicillin allergy) 1. In cases of multiple recurrences (typically defined as 7 or more infections in one year, 5 per year for two years, or 3 per year for three years), tonsillectomy may be considered after consultation with an otolaryngologist, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 1. Some key points to consider in the treatment of recurrent streptococcal pharyngitis include:

• Ensuring the child completes the full antibiotic course even if symptoms improve quickly
• Considering testing family members who may be asymptomatic carriers if infections continue despite appropriate treatment
• Being aware of the potential complications of untreated infections, such as rheumatic fever or post-streptococcal glomerulonephritis
• Documenting the frequency and clinical features of throat infection episodes to determine the need for tonsillectomy, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 1. Overall, the treatment of recurrent streptococcal pharyngitis requires a comprehensive approach that takes into account the individual child's needs and medical history, as well as the most recent and highest quality evidence available 1.

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 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. 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.

The appropriate treatment for a 12-year-old child with recurrent streptococcal pharyngitis is penicillin as the first-line therapy. Azithromycin can be used as an alternative in individuals who cannot use first-line therapy. It is essential to perform susceptibility tests to ensure the effectiveness of azithromycin against the specific strain of Streptococcus pyogenes. 2

From the Research

Treatment Options for Recurrent Streptococcal Pharyngitis

• The treatment for recurrent streptococcal pharyngitis in a 12-year-old child typically involves antibiotics, with penicillin and amoxicillin being first-line options 3.
• A 10-day course of antibiotics is usually recommended, with first-generation cephalosporins being an alternative for patients with nonanaphylactic allergies to penicillin 3.
• Azithromycin may not be the best option due to significant resistance in some parts of the United States 3, and its use has been associated with lower bacteriologic eradication rates compared to penicillin V 4.

Diagnostic Considerations

• Clinical decision rules, such as assessing for fever, tonsillar exudate, cervical lymphadenitis, and patient age, can help determine the risk of group A beta-hemolytic streptococcal infection 3.
• Rapid antigen testing can be used to confirm the diagnosis, and a throat culture may be recommended if the test result is negative 3.
• The presence of a cough is more suggestive of a viral etiology, and steroids are not recommended for symptomatic treatment 3.

Recurrence and Prevention

• Recurrent streptococcal pharyngitis can be a challenge to manage, and treatment options may need to be adjusted accordingly 5.
• Tonsillectomy is rarely recommended as a preventive measure, and is typically considered only in cases with a high frequency of episodes, such as seven episodes in 1 year, five episodes in each of the past 2 years, or three episodes in each of the past 3 years 3.
• The treatment of streptococcal tonsillitis/pharyngitis in young children is important to prevent complications such as rheumatic fever 6.