From the Guidelines
Streptococcal pharyngitis should be treated with oral penicillin V (phenoxymethylpenicillin) at 250-500 mg twice daily for 10 days for adults, or 250 mg 2-3 times daily for children, as recommended by the most recent and highest quality study 1. The treatment of streptococcal pharyngitis is crucial to prevent complications such as rheumatic fever and kidney inflammation.
- The first-line treatment is oral penicillin V, which is effective in eradicating the bacteria from the pharynx and preventing complications.
- Alternatively, amoxicillin 500 mg twice daily for adults or 50 mg/kg/day divided into two doses for children can be used for 10 days.
- For penicillin-allergic patients, macrolides like azithromycin (500 mg on day 1, then 250 mg daily for 4 more days) or first-generation cephalosporins (if no anaphylactic reaction history) are appropriate alternatives.
- Complete the full antibiotic course even if symptoms improve to prevent complications.
- Supportive care includes adequate hydration, rest, and pain management with acetaminophen or ibuprofen.
- Patients should stay home from work or school for at least 24 hours after starting antibiotics to prevent transmission. The most recent study 1 emphasizes the importance of appropriate antibiotic use for acute respiratory tract infection in adults, and the American College of Physicians and the Centers for Disease Control and Prevention recommend antibiotic therapy only for patients with a positive streptococcal test result.
- The 2012 IDSA clinical guidelines recommend antibiotic therapy for a duration likely to eradicate group A Streptococcus from the pharynx (usually 10 days) with an appropriate narrow-spectrum antibiotic.
- Specific regimens are listed in the Table, and evidence suggests that antibiotics may prevent complications from group A streptococcal infection, including acute rheumatic fever. However, it is essential to note that the evidence is not sufficient to recommend shorter courses of antibiotics, and the treatment should be individualized based on the patient's clinical presentation and medical history 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 Azithromycin is often effective in the eradication of susceptible strains of Streptococcus pyogenes from the nasopharynx 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) Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS) Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14 Day 30 Bacteriologic Eradication: Azithromycin 323/340 (95%) 255/330 (77%) Penicillin V 242/332 (73%) 206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin 336/343 (98%) 310/330 (94%) Penicillin V 284/338 (84%) 241/325 (74%)
Azithromycin is effective in the treatment of streptococcal pharyngitis, with a clinical success rate of 98% at Day 14 and 94% at Day 30, and a bacteriologic eradication rate of 95% at Day 14 and 77% at Day 30 2. It is often used as an alternative to first-line therapy in individuals who cannot use first-line therapy.
From the Research
Diagnosis of Streptococcal Pharyngitis
- Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4 degrees F (38 degrees C), tonsillar exudates, and cervical adenopathy 3
- The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 3, 4
- Available diagnostic tests include throat culture and rapid antigen detection testing, with throat culture considered the diagnostic standard 3
Treatment of Streptococcal Pharyngitis
- Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness 3
- Amoxicillin is equally effective and more palatable 3, 4
- First-generation cephalosporins are options in patients with penicillin allergy 3, 4, 5
- Erythromycin and clindamycin are also alternative treatments for patients with penicillin allergy 4, 6
- Azithromycin is not recommended due to significant resistance in some parts of the United States 5
Management and Prevention
- Chronic group A beta-hemolytic streptococcus (GABHS) colonization is common despite appropriate use of antibiotic therapy, and chronic carriers are at low risk of transmitting disease or developing invasive GABHS infections 3
- Tonsillectomy is rarely recommended as a preventive measure, and the benefits are too small to outweigh the associated costs and surgical risks 3, 5
- Nonsteroidal anti-inflammatory drugs are more effective than acetaminophen and placebo for treatment of fever and pain associated with GABHS pharyngitis 4
- Corticosteroids provide only a small reduction in the duration of symptoms and should not be used routinely 4, 5