Medications for Acute Pharyngitis
First-Line Antibiotic Treatment for Group A Streptococcal (GAS) Pharyngitis
Penicillin or amoxicillin remains the drug of choice for treating acute GAS pharyngitis due to proven efficacy, narrow spectrum, safety, low cost, and zero documented resistance worldwide. 1, 2
Preferred Regimens for Non-Allergic Patients
- Penicillin V: 50 mg/kg/day in 2-4 divided doses for 10 days (maximum 2000 mg/day) 1
- Amoxicillin: Commonly used alternative with similar efficacy, allowing for less frequent dosing 1
- Benzathine penicillin G: Single intramuscular injection of 600,000 units for patients <27 kg or 1,200,000 units for patients ≥27 kg—particularly useful when compliance is questionable 1
A full 10-day course is essential to achieve maximal pharyngeal eradication and prevent acute rheumatic fever, even though symptoms typically resolve within 3-4 days. 1, 2
Alternative Antibiotics for Penicillin-Allergic Patients
Non-Immediate (Non-Anaphylactic) Penicillin Allergy
First-generation cephalosporins are the preferred first-line alternatives for patients without immediate hypersensitivity reactions, with strong, high-quality evidence supporting their efficacy. 3, 2
- Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 3, 2
- Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days 3, 2
- Cross-reactivity risk is only 0.1% in patients with non-severe, delayed penicillin reactions 2
Immediate/Anaphylactic Penicillin Allergy
Patients with immediate hypersensitivity (anaphylaxis, angioedema, urticaria within 1 hour) must avoid all beta-lactam antibiotics including cephalosporins due to up to 10% cross-reactivity risk. 3, 2
Clindamycin is the preferred choice for immediate penicillin allergy, with strong, moderate-quality evidence and only ~1% resistance among GAS in the United States. 3, 2
- Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 3, 2
- Particularly effective in chronic streptococcal carriers who have failed penicillin treatment 1, 2
Macrolides are acceptable alternatives but carry concerns about resistance (5-8% in the United States, varying geographically). 3, 2
- Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days—the only antibiotic requiring just 5 days due to prolonged tissue half-life 3, 2, 4
- Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 3, 2
- Erythromycin: 20-40 mg/kg/day divided 2-3 times daily (maximum 1 gram per day) for 10 days—less preferred due to gastrointestinal side effects 2
Treatment for Recurrent or Chronic Carrier States
Patients with recurrent positive tests may be chronic GAS carriers experiencing intercurrent viral infections rather than true recurrent streptococcal infections. 1
Chronic carriers generally do not require antimicrobial therapy, as they are unlikely to spread infection and are at little risk for complications including acute rheumatic fever. 1
Special Situations Warranting Carrier Treatment
Treatment may be considered during: 1
- Community outbreaks of acute rheumatic fever, post-streptococcal glomerulonephritis, or invasive GAS infection
- Outbreaks in closed/partially closed communities
- Family or personal history of acute rheumatic fever
- Excessive family anxiety about GAS infections
- When tonsillectomy is being considered solely for carriage
Regimens for Chronic Carriers (When Treatment Indicated)
- Clindamycin: 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days (strong, high) 1
- Penicillin V + Rifampin: Penicillin V 50 mg/kg/day in 4 doses × 10 days (maximum 2000 mg/day); rifampin 20 mg/kg/day in 1 dose × last 4 days (maximum 600 mg/day) (strong, high) 1
- Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses (maximum 2000 mg amoxicillin/day) for 10 days (strong, moderate) 1
- Benzathine penicillin G + Rifampin: Benzathine penicillin G 600,000 units for <27 kg or 1,200,000 units for ≥27 kg (1 dose); rifampin 20 mg/kg/day in 2 doses (maximum 600 mg/day) × 4 days (strong, high) 1
Adjunctive Symptomatic Therapy
Acetaminophen or NSAIDs (such as ibuprofen) should be considered for moderate to severe symptoms or high fever, with strong, high-quality evidence for reducing pain and inflammation. 1, 5
Aspirin must be avoided in children due to the risk of Reye syndrome. 1, 5
Corticosteroids are not recommended as adjunctive therapy despite minimal reduction in pain duration (~5 hours), given the self-limited nature of GAS pharyngitis, efficacy of analgesics, and potential adverse effects. 1, 5
Critical Pitfalls to Avoid
- Do not shorten antibiotic courses below 10 days (except azithromycin's 5-day regimen), as this dramatically increases treatment failure rates and risk of acute rheumatic fever 1, 2
- Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions due to 10% cross-reactivity risk 3, 2
- Do not prescribe macrolides without considering local resistance patterns, as resistance varies geographically and can lead to treatment failure 3, 2
- Do not use trimethoprim-sulfamethoxazole (Bactrim) for strep throat due to high resistance rates (50%) and lack of efficacy against GAS 3
- Do not perform routine post-treatment throat cultures for asymptomatic patients who have completed therapy 1, 2
- Do not recommend tonsillectomy solely to reduce frequency of GAS pharyngitis (strong, high) 1
- Do not prescribe antibiotics for viral pharyngitis—the majority of acute pharyngitis cases are viral and self-limited 6, 7
Diagnostic Confirmation Before Treatment
Confirm GAS pharyngitis with rapid antigen detection test (RADT) or throat culture before prescribing antibiotics. 3, 6