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):

• 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 2, 3

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: Macrolide resistance (azithromycin, clarithromycin) varies geographically and is significant in some U.S. regions 1, 6, 7, 4. The FDA label explicitly states that azithromycin should not be relied upon to prevent rheumatic fever and susceptibility testing should be performed 7. Use macrolides only when other options are contraindicated.

Symptomatic Treatment

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

Recurrent Streptococcal Pharyngitis

First, distinguish true recurrent infections from chronic carriers with viral infections:

• Confirm each episode with RADT or throat culture 6
• Consider serotyping to differentiate reinfection from carrier state 1, 8

For documented recurrent infections:

• Clindamycin: 20-30 mg/kg/day in three doses (maximum 300 mg per dose) for 10 days 1, 6
• Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in three doses (maximum 2000 mg amoxicillin/day) for 10 days 1, 6
• Penicillin V plus rifampin: Penicillin V 50 mg/kg/day in four doses for 10 days plus rifampin 20 mg/kg/day in one dose for last 4 days (maximum rifampin 600 mg/day) 1

When to Reevaluate

• Worsening symptoms after appropriate antibiotic initiation 4
• Symptoms persisting 5 days after starting treatment 4
• Consider tonsillectomy only for extreme frequency: ≥7 episodes in 1 year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years 6, 4

Common Pitfalls to Avoid

• Overtreatment of viral pharyngitis: 60% of adults with sore throat receive antibiotics, but only 10% have streptococcal infection 4
• Incomplete treatment courses: The full 10-day course of penicillin/amoxicillin is necessary to prevent rheumatic fever 2, 3
• Once-daily penicillin dosing: Associated with 12 percentage point lower cure rate compared to more frequent dosing 5
• Routine post-treatment testing: Not recommended for asymptomatic patients 1, 2
• Testing household contacts: Not routinely recommended 1