From the Guidelines
The protocol for recurrent strep throat typically involves a combination of antibiotics, tonsillectomy consideration, and preventive measures, with medical intervention recommended for patients experiencing 7 or more episodes in one year, 5 episodes per year for two consecutive years, or 3 episodes per year for three consecutive years, as supported by the most recent guidelines 1.
Key Considerations
- The first-line antibiotic treatment remains penicillin V (250-500 mg twice daily for 10 days for adults; 250 mg twice daily for children under 27 kg), or amoxicillin (500 mg twice daily for adults; 50 mg/kg/day divided twice daily for children) for 10 days, as indicated by studies 1.
- For penicillin-allergic patients, alternatives include clindamycin (300 mg three times daily for adults; 20-30 mg/kg/day divided three times daily for children) or azithromycin (500 mg on day 1, then 250 mg daily for 4 days for adults; 12 mg/kg daily for 5 days for children).
- Tonsillectomy should be discussed for patients meeting frequency criteria, as it can reduce recurrence rates by eliminating the primary reservoir for streptococcal bacteria, according to the guidelines 1.
Preventive Measures
- Replacing toothbrushes after infections
- Avoiding sharing personal items
- Testing family members who may be asymptomatic carriers
Special Considerations
- Chronic streptococcal carriers may require different management strategies, including the use of antimicrobial therapy to eliminate carriage, as discussed in the guidelines 1.
- The distinction between persistent carriage and recurrent episodes of acute GAS pharyngitis can be challenging, and may require additional testing and evaluation, as noted in the studies 1.
From the FDA Drug Label
Pharyngitis/Tonsillitis In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes)
Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14Day 30 Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%) Penicillin V242/332 (73%)206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%) Penicillin V284/338 (84%)241/325 (74%)
The recommended treatment protocol for recurrent strep throat is azithromycin (12 mg/kg once a day for 5 days) or penicillin V (250 mg three times a day for 10 days).
- Bacteriologic eradication rates at Day 14 and Day 30 were 95% and 77% for azithromycin, and 73% and 63% for penicillin V, respectively.
- Clinical success rates at Day 14 and Day 30 were 98% and 94% for azithromycin, and 84% and 74% for penicillin V, respectively 2.
From the Research
Recurrent Strep Throat Protocol
- The American Family Physician recommends using clinical decision rules to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear, before prescribing antibiotics 3.
- Guidelines suggest that fever, tonsillar exudate, cervical lymphadenitis, and patient ages of 3 to 15 years increase clinical suspicion, while a cough is more suggestive of a viral etiology 3.
- Penicillin and amoxicillin are first-line antibiotics, with a recommended course of 10 days; first-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 3, 4.
- There is significant resistance to azithromycin and clarithromycin in some parts of the United States, making them less ideal options 3.
- For recurrent strep throat, tonsillectomy is rarely recommended as a preventive measure, with commonly used thresholds including seven episodes of streptococcal pharyngitis in 1 year, five episodes in each of the past 2 years, or three episodes in each of the past 3 years 3.
- Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment should be reevaluated 3.
- Alternative treatment options to standard penicillin therapy may be considered to avoid problems of noncompliance, as discussed by Dr Ruoff 5.