From the Guidelines
Strep pharyngitis is primarily treated with antibiotics, with penicillin being the first-line treatment, as recommended by the Infectious Diseases Society of America 1.
Treatment Options
For adults, the recommended regimen is penicillin V 500 mg orally twice daily for 10 days, or a single intramuscular injection of benzathine penicillin G 1.2 million units if oral compliance is a concern.
- For penicillin-allergic patients, alternatives include cephalexin 500 mg twice daily for 10 days (if no anaphylactic reaction history), or azithromycin 500 mg on day 1 followed by 250 mg daily for days 2-5, as suggested by the 2012 update by the Infectious Diseases Society of America 1.
- Amoxicillin is also effective at 500 mg twice daily or 1000 mg once daily for 10 days and may be preferred for children due to better taste.
Importance of Completing the Full Course
It is crucial to complete the full antibiotic course even if symptoms improve to prevent complications like rheumatic fever, as emphasized in the practice guidelines for the diagnosis and management of group A streptococcal pharyngitis 1.
Symptomatic Relief
Symptomatic relief can be achieved with acetaminophen or ibuprofen for pain and fever, and salt water gargles for throat discomfort.
Return to Work or School
Patients should rest, stay hydrated, and can typically return to work or school after 24 hours of antibiotic therapy when they're no longer contagious, as supported by the clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis 1.
From the FDA Drug Label
Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy. Azithromycin is often effective in the eradication of susceptible strains of Streptococcus pyogenes from the nasopharynx In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS)
Treatment for strep pharyngitis: Azithromycin is effective in the treatment of pharyngitis/tonsillitis caused by Streptococcus pyogenes, with a clinical success rate of 98% at Day 14 and 94% at Day 30, as compared to penicillin V. However, penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever. Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy 2.
From the Research
Diagnosis and Treatment
- The diagnosis of streptococcal pharyngitis can be made using throat culture and rapid antigen detection testing, with throat culture being the diagnostic standard 3.
- The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 3, 4.
- Clinical decision rules, such as the modified Centor or FeverPAIN score, can be used to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear 5, 4.
Antibiotic Treatment
- Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice for streptococcal pharyngitis due to its cost, narrow spectrum of activity, and effectiveness 3.
- Amoxicillin is equally effective and more palatable than penicillin 3, 5.
- First-generation cephalosporins are options in patients with penicillin allergy 3, 5.
- Macrolides, such as azithromycin, may be used as an alternative to penicillin, but there is limited evidence to support their use 6.
- Carbacephem may be more effective than penicillin for symptom resolution in adults and children, but the evidence is limited 6.
Symptomatic Treatment
- Nonsteroidal anti-inflammatory drugs are more effective than acetaminophen and placebo for treatment of fever and pain associated with streptococcal pharyngitis 4.
- Medicated throat lozenges used every two hours are also effective for symptomatic treatment 4.
- Corticosteroids provide only a small reduction in the duration of symptoms and should not be used routinely 4.
Prevention and Complications
- Tonsillectomy is rarely recommended as a preventive measure for streptococcal pharyngitis, and is typically considered for patients with recurrent episodes of streptococcal pharyngitis 3, 5.
- The risk of complications, such as acute rheumatic fever and post-streptococcal glomerulonephritis, is low in high-income countries, but may be higher in low-income countries and Aboriginal communities 6.