From the Guidelines
Strep throat should be treated with penicillin or amoxicillin for 10 days to reduce symptom duration and prevent serious complications like rheumatic fever and kidney inflammation. The standard treatment for adults is penicillin V 500 mg orally twice daily for 10 days, or amoxicillin 500 mg three times daily for 10 days 1. For children, the dosage is weight-based, typically amoxicillin 50 mg/kg/day divided into two or three doses for 10 days. For patients with penicillin allergy, alternatives include azithromycin (500 mg on day 1, then 250 mg daily for 4 more days for adults) or clindamycin (300 mg three times daily for 10 days) 1.
Some key points to consider when treating strep throat include:
- Completing the full course of antibiotics even if symptoms improve before finishing the medication
- Using rest, increased fluid intake, saltwater gargles, and over-the-counter pain relievers like acetaminophen or ibuprofen to manage symptoms
- Preventing serious complications like rheumatic fever and kidney inflammation
- Most patients begin feeling better within 24-48 hours of starting antibiotics, and they're generally no longer contagious after 24 hours of antibiotic treatment
It's also important to note that penicillin remains the treatment of choice because of its proven efficacy and safety, and its narrow spectrum and low cost 1. Additionally, antimicrobial resistance has not been a significant issue in the treatment of group A streptococcal pharyngitis in the United States, with no clinical isolate of group A Streptococcus anywhere in the world documented to be resistant to penicillin 1.
In terms of prevention of rheumatic fever, primary prevention is accomplished by proper identification and adequate antibiotic treatment of group A -hemolytic streptococcal (GAS) tonsillopharyngitis, and penicillin is the treatment of choice 1. For individuals who have had an attack of rheumatic fever, continuous antimicrobial prophylaxis is needed to prevent recurrences, and the recommended duration of prophylaxis depends on several factors, including the number of previous attacks and the risk of exposure to GAS infections 1.
From the FDA Drug Label
In streptococcal infections, therapy must be sufficient to eliminate the organism (10-day minimum); otherwise the sequelae of streptococcal disease may occur. NOTE: Penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever. Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy.
Strep Treatment:
- The recommended treatment for streptococcal infections is penicillin for a minimum of 10 days to eliminate the organism and prevent sequelae of streptococcal disease 2.
- Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy for pharyngitis/tonsillitis caused by Streptococcus pyogenes 3 3.
From the Research
Strep Treatment Options
- Penicillin V is a commonly used treatment for streptococcal pharyngitis, with a recommended dosage of 250 mg twice daily or 500 mg twice daily for 10 days 4, 5
- Alternative treatments include amoxicillin, erythromycin, and first-generation cephalosporins, which can be used in patients with penicillin allergy 6, 7
- A short-course of clarithromycin (5 days) has been shown to be comparable to a standard course of penicillin V (10 days) in eradicating Streptococcus pyogenes 8
Treatment Duration and Frequency
- Penicillin V can be given twice daily, with a treatment duration of 10 days 4
- A treatment regimen of penicillin V 500 mg twice daily is recommended for the treatment of pharyngitis due to group A beta-hemolytic streptococci (GABHS) 5
- Giving penicillin once daily may be less effective than giving it twice or four times daily, with a higher likelihood of persistent positive culture after 48 hours treatment and recurrent positive cultures after end of treatment 5
Treatment Efficacy
- Penicillin V given twice daily has been shown to be as effective as penicillin V given three times daily for the treatment of GABHS pharyngitis 4
- Clarithromycin ER 500 mg once daily for 5 days has been shown to be equally effective as penicillin V 500 mg three times daily for 10 days in the treatment of adolescent and adult patients with streptococcal tonsillopharyngitis 8
- Cephalosporins have been associated with a lower rate of clinical failure compared to penicillins, but have drawbacks in cost, administration frequency, and adverse effect profile 7