Treatment of Streptococcal Pharyngitis in a 5-Year-Old
Treat with amoxicillin 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days. 1
First-Line Antibiotic Selection
Amoxicillin or penicillin V are the preferred first-line agents due to their narrow spectrum, minimal adverse effects, low cost, and strong evidence base. 1
Amoxicillin Dosing (Preferred for palatability in young children):
- 50 mg/kg once daily (maximum 1,000 mg), OR 1
- 25 mg/kg twice daily (maximum 500 mg per dose) 1
- Duration: 10 full days 1, 2
Penicillin V Dosing (Alternative):
Intramuscular Option (for compliance concerns):
- Benzathine penicillin G 600,000 units IM (single dose) for children <27 kg 1
Critical Treatment Principles
The 10-day duration is non-negotiable for Group A Streptococcal pharyngitis to prevent acute rheumatic fever, regardless of symptom resolution. 1, 2 While research shows 5-day courses may achieve clinical cure in pneumonia 3, guidelines do not endorse shorter courses for strep throat due to rheumatic fever prevention. 4
Administer at the start of a meal to minimize gastrointestinal intolerance. 2
Penicillin Allergy Alternatives
If the child has a documented penicillin allergy:
Non-immediate hypersensitivity:
- Cephalexin 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
- Cefadroxil 30 mg/kg once daily (maximum 1 g) for 10 days 1
Immediate (Type I) hypersensitivity:
- Clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1
- Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days 1
- Clarithromycin 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1
Important caveat: Macrolides (azithromycin, clarithromycin) have increasing resistance rates and should only be used when beta-lactams are contraindicated. 1, 5 In areas with high clarithromycin resistance (>26% in some studies), these agents may fail to eradicate Group A Streptococcus. 5
Adjunctive Symptomatic Treatment
- Acetaminophen or ibuprofen for fever and pain control 1
- Never use aspirin in children due to Reye's syndrome risk 1
- Do not use corticosteroids for routine strep pharyngitis 1
Common Pitfalls to Avoid
Do not stop antibiotics early even if symptoms resolve within 3-4 days—this increases rheumatic fever risk. 4 The child typically becomes non-contagious after 12-24 hours of appropriate antibiotic therapy and may return to school if afebrile and improved. 6
Do not perform routine post-treatment testing unless the child has specific risk factors (personal/family history of rheumatic fever, outbreak situations, or persistent symptoms). 1
Do not test or treat household contacts unless they are symptomatic. 1
Avoid sulfonamides, trimethoprim, tetracyclines, and fluoroquinolones—these are not acceptable for Group A Streptococcal pharyngitis. 1
When to Consider Alternative Approaches
If the child has recurrent positive cultures despite treatment, consider chronic carrier state with concurrent viral infections rather than treatment failure. 1 In this scenario, antibiotics may not be necessary unless specific high-risk circumstances exist (rheumatic fever outbreak, family history of rheumatic fever, or excessive parental anxiety). 1