What is the recommended treatment for strep throat?

Treatment for Strep Throat

Penicillin or amoxicillin for 10 days is the first-line treatment for strep throat in patients without penicillin allergy, with amoxicillin being preferred due to better palatability and equal effectiveness. 1, 2

First-Line Treatment for Non-Allergic Patients

Penicillin and amoxicillin remain the drugs of choice due to their proven efficacy, narrow spectrum of activity, safety profile, and low cost, with no documented penicillin resistance in Group A Streptococcus anywhere in the world. 1, 3, 2

Recommended Dosing Regimens:

Amoxicillin (preferred for palatability):

• Children: 50 mg/kg once daily (maximum 1,000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2, 4
• Adults: 500 mg twice daily OR 875 mg twice daily for severe infections, for 10 days 1, 4
• Research shows amoxicillin at 40 mg/kg/day achieves 87.9% clinical cure versus 70.9% with standard penicillin dosing 5

Penicillin V:

• Children: 250 mg two or three times daily for 10 days 1, 2
• Adolescents/Adults: 250 mg four times daily OR 500 mg twice daily for 10 days 1, 2
• Twice-daily dosing is as effective as more frequent dosing and improves compliance 6

Intramuscular Benzathine Penicillin G (single dose):

• Patients <60 lb (27 kg): 600,000 units 1, 2
• Patients ≥60 lb: 1,200,000 units 1, 2
• Use this option when compliance with oral therapy is questionable 1, 2

Treatment for Penicillin-Allergic Patients

The choice of alternative antibiotic depends critically on the type of penicillin allergy—this distinction is essential for safe prescribing. 3

For Non-Immediate (Non-Anaphylactic) Penicillin Allergy:

First-generation cephalosporins are the preferred alternatives with strong, high-quality evidence supporting their use. 1, 3

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 1, 3
• Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days 1, 3
• Cross-reactivity risk is only 0.1% in patients with non-severe, delayed penicillin reactions 3

For Immediate/Anaphylactic Penicillin Allergy:

Avoid ALL beta-lactam antibiotics (including cephalosporins) due to up to 10% cross-reactivity risk in patients with immediate hypersensitivity reactions such as anaphylaxis, angioedema, respiratory distress, or urticaria occurring within 1 hour. 1, 3

Clindamycin is the preferred choice:

• Dosing: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1, 3
• Only ~1% resistance rate among Group A Streptococcus in the United States 3
• Particularly effective in chronic carriers who have failed penicillin treatment 3

Macrolide alternatives (second-line due to resistance concerns):

• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days only 1, 3
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 1, 3
• Macrolide resistance is 5-8% in the United States and varies geographically 3, 7
• Azithromycin is the ONLY antibiotic requiring just 5 days due to its prolonged tissue half-life 3

Critical Treatment Duration Requirements

A full 10-day course is essential (except azithromycin's 5-day regimen) to achieve maximal pharyngeal eradication of Group A Streptococcus and prevent acute rheumatic fever. 1, 3, 2, 4

• Shortening the course by even a few days results in appreciable increases in treatment failure rates and rheumatic fever risk 3
• Treatment can be safely postponed up to 9 days after symptom onset and still prevent acute rheumatic fever 3
• Symptoms typically resolve within 3-4 days without treatment, but full course completion is essential for preventing complications 3

Adjunctive Therapy

For symptom management:

• Acetaminophen or NSAIDs (ibuprofen) for moderate to severe symptoms or high fever 1, 3, 2
• Aspirin must be avoided in children due to Reye syndrome risk 1, 3
• Corticosteroids are NOT recommended as adjunctive therapy 1, 3

Common Pitfalls to Avoid

Do not prescribe antibiotics without testing when clinical features strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers). 1, 2

Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions—the 10% cross-reactivity risk makes this dangerous. 3

Do not prescribe azithromycin or clarithromycin as first-line therapy—reserve macrolides for true penicillin-allergic patients, and be aware of local resistance patterns. 3, 7

Do not shorten antibiotic courses below 10 days (except azithromycin's 5-day regimen)—this dramatically increases treatment failure and rheumatic fever risk. 3

Do not perform routine post-treatment throat cultures in asymptomatic patients who have completed therapy—testing should only be considered in special circumstances such as patients with a history of rheumatic fever. 3, 2

Do not use trimethoprim-sulfamethoxazole (Bactrim) for strep throat—it has high resistance rates (50%) and is not recommended for Group A Streptococcus. 3

Special Considerations

For recurrent pharyngitis with laboratory evidence of Group A Streptococcus:

• These patients may be chronic carriers experiencing repeated viral infections 1
• Chronic carriers generally do not require antimicrobial therapy as they are unlikely to spread infection or develop complications 3
• Consider treatment only in specific situations: community outbreaks, family/personal history of rheumatic fever, or excessive anxiety about infections 1
• Clindamycin may be particularly effective for chronic carriers due to its ability to eradicate the organism 3

Patients become non-contagious after 24 hours of appropriate antibiotic therapy. 8