What is the recommended treatment for strep throat?

Treatment of Streptococcal Pharyngitis

Penicillin or amoxicillin for 10 days is the first-line treatment for confirmed group A streptococcal pharyngitis, with penicillin V (250 mg twice daily for children, 500 mg twice daily for adults) or amoxicillin (50 mg/kg once daily, maximum 1000 mg) as equally effective options. 1, 2, 3

Diagnostic Confirmation Before Treatment

• Do not prescribe antibiotics without diagnostic confirmation via rapid antigen detection test (RADT) or throat culture 2, 3, 4
• In children and adolescents, back up negative RADT results with throat culture 2, 3
• Skip testing entirely if clinical features strongly suggest viral etiology (cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis) 1, 3
• Use clinical decision rules (Centor criteria) to assess pretest probability: fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough increase likelihood of streptococcal infection 1, 4

First-Line Antibiotic Regimens (Non-Allergic Patients)

Oral penicillin V for 10 days:

• Children: 250 mg twice or three times daily 1, 2, 3
• Adolescents/adults: 500 mg twice daily or 250 mg four times daily 1, 2, 3
• Twice-daily dosing is as effective as more frequent dosing and improves compliance 5

Oral amoxicillin for 10 days (preferred in young children due to taste):

• 50 mg/kg once daily (maximum 1000 mg) 1, 2, 3
• Alternative: 25 mg/kg twice daily (maximum 500 mg per dose) 1
• Once-daily amoxicillin is effective, unlike once-daily penicillin which shows decreased efficacy 5

Intramuscular benzathine penicillin G (single dose):

• Use when compliance with oral therapy is questionable 1, 2, 3
• <60 lb (27 kg): 600,000 units 1, 2
• ≥60 lb: 1,200,000 units 1, 2

Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy (first-generation cephalosporins for 10 days):

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) 1, 6
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) 1, 6

For anaphylactic penicillin allergy:

• Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1, 6, 3
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 6
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 1, 6

Critical Caveat on Macrolides

Macrolide resistance (azithromycin, clarithromycin) varies geographically and temporally—check local resistance patterns before prescribing. 1, 6, 7 The FDA label explicitly states that azithromycin should not be relied upon to prevent rheumatic fever, and susceptibility testing should be performed when treating with azithromycin 7. Despite this, macrolides remain guideline-recommended alternatives for penicillin-allergic patients 1, 6.

Symptomatic Treatment

• Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1, 2, 6, 3
• Never use aspirin in children due to Reye syndrome risk 1, 6, 3
• Corticosteroids are not recommended 1, 6, 3

Duration and Compliance

The full 10-day course is essential to ensure complete eradication and prevent rheumatic fever 2, 3. Poor compliance is a primary cause of treatment failure 8. Twice-daily penicillin or once-daily amoxicillin regimens improve adherence compared to more frequent dosing 5.

Recurrent Streptococcal Pharyngitis

Distinguish true recurrent infections from chronic carriers experiencing viral infections:

• Confirm each episode with RADT or culture 6, 3
• Chronic carriers (asymptomatic with positive cultures) do not routinely need treatment unless specific circumstances exist: community outbreak, family history of rheumatic fever, or excessive anxiety 1

Treatment options for documented recurrent infections:

• Clindamycin: 20-30 mg/kg/day in three doses (maximum 300 mg per dose) for 10 days 1
• Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in three doses (maximum 2000 mg/day) for 10 days 1
• Benzathine penicillin G (single dose) plus rifampin: 20 mg/kg/day for 4 days (maximum 600 mg/day) 1

When to Reevaluate

Reassess patients with:

• Worsening symptoms after appropriate antibiotic initiation 4
• Symptoms persisting 5 days after starting treatment 4

Tonsillectomy Considerations

Consider tonsillectomy only for severe recurrent cases:

• ≥7 episodes in 1 year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years 6, 4
• Each episode must be documented with positive RADT or culture 6

Common Pitfalls to Avoid

• Overtreatment of viral pharyngitis: 60% of adults with sore throat receive antibiotics, but only 10% have streptococcal infection 4
• Prescribing antibiotics without diagnostic confirmation 2, 3
• Using once-daily penicillin (associated with 12 percentage point lower cure rate compared to more frequent dosing) 5
• Incomplete 10-day courses leading to treatment failure and increased rheumatic fever risk 2, 3, 8
• Routine post-treatment testing in asymptomatic patients is not recommended 1, 2
• Testing household contacts is not routinely indicated 1