What is the best medication for strep throat?

Best Medication for Strep Throat

Penicillin V (250 mg three times daily or 500 mg twice daily for 10 days) or amoxicillin (50 mg/kg once daily for children, maximum 1000 mg, for 10 days) are the best medications for strep throat due to their proven efficacy, narrow spectrum, safety profile, and low cost. 1, 2

First-Line Treatment: Penicillin or Amoxicillin

Both the Infectious Diseases Society of America and the American Academy of Pediatrics strongly recommend penicillin or amoxicillin as first-line therapy for Group A streptococcal pharyngitis, with strong, high-quality evidence supporting this recommendation. 1, 2

Specific Dosing Regimens:

• Adults and older children: Penicillin V 250 mg three to four times daily OR 500 mg twice daily for 10 days 1, 2
• Younger children: Amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days is preferred due to better taste acceptance and availability as suspension 2
• When compliance is uncertain: Intramuscular benzathine penicillin G 1.2 million units as a single injection is preferred 2

Why Penicillin/Amoxicillin Remains Superior:

• No documented penicillin resistance exists anywhere in the world among Group A Streptococcus 2
• Narrow spectrum minimizes disruption of normal flora and reduces selection pressure for antibiotic resistance 1, 2
• Proven prevention of acute rheumatic fever when given for full 10-day course 1, 2
• Significantly lower cost compared to alternatives 1

Critical Treatment Duration Requirement

A full 10-day course is essential for all antibiotics except azithromycin (which requires 5 days). 1, 2 Shortening the course by even a few days results in appreciable increases in treatment failure rates and risk of acute rheumatic fever. 2 The 10-day duration achieves maximal pharyngeal eradication of Group A Streptococcus, which is necessary to prevent complications. 1, 2

Alternatives for Penicillin-Allergic Patients

Non-Immediate (Non-Anaphylactic) Penicillin Allergy:

First-generation cephalosporins are the preferred alternative, with strong, high-quality evidence supporting their use. 1, 2, 3

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg/dose) for 10 days 2, 3
• Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days 3
• Cross-reactivity risk is only 0.1% in patients with non-severe, delayed penicillin reactions 3

Immediate/Anaphylactic Penicillin Allergy:

Patients with immediate hypersensitivity (anaphylaxis, angioedema, respiratory distress, or urticaria within 1 hour) must avoid ALL beta-lactam antibiotics including cephalosporins due to up to 10% cross-reactivity risk. 1, 2, 3

Clindamycin is the preferred alternative for immediate penicillin allergy, with strong, moderate-quality evidence: 1, 2, 3

• Dosing: 7 mg/kg per dose three times daily (maximum 300 mg/dose) for 10 days 2, 3
• Resistance rate is only ~1% in the United States 2, 3
• Particularly effective in chronic streptococcal carriers who have failed penicillin 2, 3

Macrolides (azithromycin, clarithromycin) are acceptable alternatives but less preferred: 1, 2, 3

• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 2, 3
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg/dose) for 10 days 3
• Macrolide resistance is 5-8% in the United States and varies geographically 2, 3
• No data proving azithromycin prevents rheumatic fever 2, 4

Common Pitfalls to Avoid

• Do NOT use azithromycin or macrolides as first-line when penicillin can be used - reserve for documented penicillin allergy 2
• Do NOT assume all penicillin-allergic patients cannot receive cephalosporins - only those with immediate/anaphylactic reactions should avoid them 2, 3
• Do NOT prescribe shorter courses than recommended (except azithromycin's 5-day regimen) - this dramatically increases treatment failure and rheumatic fever risk 2
• Do NOT use trimethoprim-sulfamethoxazole (Bactrim) - high resistance rates (50%) make it ineffective for Group A Streptococcus 2
• Do NOT prescribe amoxicillin to adolescents without considering Epstein-Barr virus risk - mononucleosis can cause rash with amoxicillin 2

When to Consider Antibiotics

Antibiotics should NOT be used in patients with 0-2 Centor criteria (low probability of strep throat). 1, 2 For patients with 3-4 Centor criteria (high probability), discuss the modest benefits versus risks including side effects, antibiotic resistance, and medicalization. 1, 2

Adjunctive Therapy

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