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

Treatment of Streptococcal Pharyngitis

Penicillin or amoxicillin for 10 days is the recommended first-line treatment for streptococcal pharyngitis in patients without penicillin allergy. 1, 2

First-Line Treatment for Non-Allergic Patients

Penicillin V remains the drug of choice based on its narrow spectrum, proven efficacy in preventing rheumatic fever, minimal adverse effects, and low cost 1, 2. The recommended dosing is:

• Children: Penicillin V 250 mg two or three times daily for 10 days 2
• Adolescents and adults: Penicillin V 250 mg four times daily OR 500 mg twice daily for 10 days 2

Amoxicillin is an equally acceptable first-line option with more convenient dosing 1, 2:

• Children: 50 mg/kg once daily (maximum 1,000 mg) OR 25 mg/kg twice daily (maximum 500 mg) for 10 days 2

Intramuscular benzathine penicillin G (single dose) should be considered when compliance with oral therapy is questionable 2:

• Patients <60 lb (27 kg): 600,000 units 2
• Patients ≥60 lb: 1,200,000 units 2

The 10-day duration is critical for complete bacterial eradication and rheumatic fever prevention, despite some studies suggesting shorter courses with cephalosporins 1, 2.

Treatment for Penicillin-Allergic Patients

The choice depends on the type of allergy:

For non-anaphylactic penicillin allergy, first-generation cephalosporins for 10 days 1, 3:

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) 3
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) 3

For anaphylactic penicillin allergy, use alternatives for 10 days (except azithromycin) 1, 3:

• Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 3
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 3
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 3

Important caveat: Macrolide resistance (azithromycin and clarithromycin) varies geographically and should be considered when selecting treatment 3. The FDA label notes that some strains are resistant to azithromycin and susceptibility testing should be performed 4. Additionally, data establishing azithromycin's efficacy in preventing rheumatic fever are not available 4.

Diagnostic Confirmation Before Treatment

Testing is essential before prescribing antibiotics to avoid overtreatment of viral pharyngitis 1, 2:

• Do NOT test or treat patients with clear viral features: cough, rhinorrhea, hoarseness, or oral ulcers 1, 5
• Rapid antigen detection test (RADT) is diagnostic if positive and requires no backup culture 2, 3
• Backup throat culture is recommended for children and adolescents with negative RADT results 2
• Do NOT test children <3 years old routinely, as streptococcal pharyngitis and rheumatic fever are rare in this age group 1

Adjunctive Symptomatic Treatment

Analgesics should be offered for symptom relief 1, 2:

• Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1, 2, 5
• Aspirin must be avoided in children due to Reye syndrome risk 1, 2, 5
• Corticosteroids are NOT recommended for routine use 1, 3

Management of Recurrent Streptococcal Pharyngitis

Distinguish between true recurrent infections versus chronic carriage with viral infections 1, 3. Each episode must be confirmed with RADT or throat culture before retreating 3.

For confirmed recurrent cases 2, 3:

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

Tonsillectomy may be considered only for children meeting specific frequency criteria: ≥7 episodes in 1 year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years 3.

Common Pitfalls to Avoid

• Do NOT prescribe antibiotics for viral pharyngitis with cough, rhinorrhea, or hoarseness—this provides no benefit and promotes resistance 1, 5
• Do NOT perform routine post-treatment cultures in asymptomatic patients 1, 3
• Do NOT test or treat asymptomatic household contacts 1
• Do NOT rely on clinical features alone—the classic triad of fever, exudate, and adenopathy is present in only 15% of cases 6
• Be aware of macrolide resistance in your geographic area before prescribing azithromycin or clarithromycin 3