What is the recommended treatment duration for streptococcal (strep) pharyngitis before returning to school?

From the Guidelines

Children with strep throat should stay home from school until they have been on antibiotics for at least 24 hours, as this is the timeframe during which they are generally no longer contagious and can safely return to school or daycare. The most common antibiotic prescribed for strep throat is penicillin or amoxicillin, typically taken for a full 10-day course, as recommended by the Infectious Diseases Society of America 1. Even though your child may return to school after 24 hours of antibiotics, it's crucial to complete the entire prescribed course of medication to fully eliminate the infection and prevent complications like rheumatic fever, as emphasized in the clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis 1. During treatment, encourage plenty of fluids, soft foods if swallowing is painful, and over-the-counter pain relievers like acetaminophen or ibuprofen for discomfort. The 24-hour guideline exists because strep bacteria spread through respiratory droplets, and antibiotic treatment quickly reduces the bacterial load to non-contagious levels within this timeframe, making it safe for children to be around others. Key points to consider include:

• The importance of accurate diagnosis of streptococcal pharyngitis to prevent inappropriate antimicrobial therapy 1
• The need to complete the full 10-day course of antibiotics to prevent complications and ensure the infection is fully eliminated 1
• The role of antibiotic treatment in reducing contagiousness and allowing children to safely return to school or daycare 1

From the FDA Drug Label

It is recommended that there be at least 10 days’ treatment for any infection caused by Streptococcus pyogenes to prevent the occurrence of acute rheumatic fever. Treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic, or evidence of bacterial eradication has been obtained In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum): otherwise the sequelae of streptococcal disease may occur.

The patient should be treated for at least 10 days with amoxicillin or penicillin to prevent the occurrence of acute rheumatic fever.

• The treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic.
• Patients can return to school after completion of 24 hours of antibiotic therapy is not explicitly stated, but it is generally recommended that patients with strep throat can return to school after 24 hours of antibiotic therapy and once their symptoms have improved, however this information is not present in the provided drug labels. 2 3

From the Research

Treatment Duration for Strep Throat Before Returning to School

• The American Academy of Pediatrics Committee on Infectious Diseases recommends that patients with group A beta-hemolytic streptococcal pharyngitis should complete a full 24 hours of antibiotics before returning to school or daycare 4.
• A study published in Pediatrics found that 39 (83%) of the patients became "culture negative" within the first 24 hours of initiating antibiotic therapy, suggesting that completing a full 24 hours of antibiotics is necessary before returning to school 4.
• Another study published in American Family Physician recommends a 10-day course of penicillin or amoxicillin as first-line treatment for group A beta-hemolytic streptococcal pharyngitis, but does not specify the exact duration of treatment required before returning to school 5, 6.
• There is no firm evidence that antibiotics reduce the risk of acute glomerulonephritis, but they do accelerate symptom relief and prevent locoregional suppuration 7.
• A Cochrane review found that cephalosporins, macrolides, and carbacephem may be effective alternatives to penicillin for the treatment of group A streptococcal pharyngitis, but the evidence is uncertain and more research is needed 8.

Key Findings

• Completing a full 24 hours of antibiotics is recommended before returning to school or daycare 4.
• The choice of antibiotic and duration of treatment may vary depending on the individual patient and the severity of the infection 5, 7, 6, 8.
• More research is needed to determine the most effective treatment strategies for group A streptococcal pharyngitis and to reduce the risk of complications 7, 8.