What is the recommended treatment for strep (streptococcal) pharyngitis?

Treatment of Streptococcal Pharyngitis

Penicillin or amoxicillin are the first-line antibiotics for streptococcal pharyngitis due to their proven efficacy, safety, narrow spectrum, and low cost. 1

First-Line Treatment for Patients Without Penicillin Allergy

Oral Penicillin V (10-day course)

• Children: 250 mg two or three times daily 1
• Adolescents and adults: 250 mg four times daily OR 500 mg twice daily 1

Oral Amoxicillin (10-day course)

• Pediatric dosing: 50 mg/kg once daily (maximum 1,000 mg) OR 25 mg/kg twice daily (maximum 500 mg) 1
• This represents an equally effective alternative to penicillin V with more convenient dosing 1

Intramuscular Benzathine Penicillin G (single dose)

• Reserved for patients unlikely to complete oral therapy 1
• Dosing: 600,000 units for patients <60 lb (27 kg); 1,200,000 units for patients ≥60 lb 1
• This ensures complete treatment in non-compliant patients 1

Treatment for Penicillin-Allergic Patients

Non-Anaphylactic Penicillin Allergy

First-generation cephalosporins are preferred (10-day course) 2:

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) 2
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) 2

Anaphylactic Penicillin Allergy

Clindamycin is the preferred alternative 2:

• Dosing: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 2

Macrolides are acceptable alternatives but have important limitations 2:

• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 2
• Critical caveat: Macrolide resistance varies geographically and should be considered when selecting treatment 2
• Azithromycin is FDA-approved as an alternative to first-line therapy in individuals who cannot use first-line therapy 3
• Azithromycin demonstrated 95% bacteriologic eradication at Day 14 versus 73% with penicillin V, though this dropped to 77% versus 63% at Day 30 3

Diagnostic Confirmation Before Treatment

Testing is essential before prescribing antibiotics 1:

• Test patients with sudden onset sore throat, fever, headache, tonsillopharyngeal inflammation/exudates, and tender anterior cervical lymphadenopathy 1
• Do NOT test or treat patients with viral features: cough, rhinorrhea, hoarseness, or oral ulcers 1, 4
• A positive rapid antigen detection test (RADT) is diagnostic and sufficient to start treatment 1
• Backup throat culture is recommended for children and adolescents with negative RADT results 1

Duration and Rationale

A standard 10-day course is required for penicillin, amoxicillin, cephalosporins, clindamycin, and clarithromycin 1:

• This ensures complete eradication of the organism 1
• Prevents rheumatic fever, the primary goal of treatment 1
• Azithromycin is the only exception with a 5-day course due to prolonged tissue half-life 2, 3

Symptomatic Management

Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1:

• Never use aspirin in children due to Reye syndrome risk 1, 4
• Corticosteroids are not recommended for routine use 2

Management of Recurrent Streptococcal Pharyngitis

Confirm each episode with RADT or throat culture before retreating 2:

• Distinguish between true recurrent infections versus chronic carriage with viral infections 2

Treatment options for confirmed recurrent cases 2:

• Retreatment with the same initial agent 2
• Intramuscular benzathine penicillin G if oral compliance is questionable 2
• Clindamycin or amoxicillin/clavulanate for chronic carriers 2

Consider tonsillectomy only for specific frequency criteria 2:

• ≥7 episodes in 1 year, OR
• ≥5 episodes per year for 2 years, OR
• ≥3 episodes per year for 3 years 2
• Otherwise, watchful waiting is recommended 2

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for viral pharyngitis with cough, rhinorrhea, hoarseness, or oral ulcers 1, 4
• Do not perform routine post-treatment throat cultures in asymptomatic patients 1
• Do not use macrolides in areas with high resistance rates without susceptibility testing 2, 3
• Do not use aspirin in children with any pharyngitis due to Reye syndrome risk 1, 4
• Ensure 10-day completion of oral antibiotics, as compliance failure is a major cause of treatment failure 1