What is the treatment plan for a 6-year-old female patient with streptococcal pharyngitis (strep throat) and hyperpyrexia (fever of 104 degrees Fahrenheit)?

Treatment Plan for 6-Year-Old with Streptococcal Pharyngitis and 104°F Fever

Start amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days and give acetaminophen or ibuprofen immediately for fever control. 1, 2

Immediate Management

Fever Control

• Administer acetaminophen or ibuprofen immediately to reduce the 104°F fever and provide pain relief 1, 2, 3
• Never use aspirin in children due to the risk of Reye syndrome 1, 2, 3
• The fever and constitutional symptoms typically resolve within 3-4 days even without antibiotics, but treatment shortens symptom duration by 1-2 days 1, 3

Antibiotic Selection

• First-line choice: Amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days 1, 2

  • This once-daily dosing enhances adherence compared to multiple daily doses 1, 2
  • Amoxicillin suspension is more palatable than penicillin V suspension, making it ideal for children 1

• Alternative: Penicillin V 250 mg twice or three times daily for 10 days 1

  • Group A streptococcus has never developed resistance to penicillin 1

If Penicillin Allergy

Non-Anaphylactic Allergy

• First-generation cephalosporin (cephalexin or cefadroxil) for 10 days 1, 2, 4
• Up to 10% of penicillin-allergic patients may also react to cephalosporins 1

Anaphylactic Allergy

• Clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 4
• Clarithromycin 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1, 4
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 2, 5
  • Note: Azithromycin is the only antibiotic approved for a shorter 5-day course 2
  • Geographic resistance to macrolides varies and should be considered 4

Critical Treatment Principles

Duration Matters

• The full 10-day course is essential to maximize bacterial eradication and prevent acute rheumatic fever 1, 2
• Treatment can be safely started up to 9 days after symptom onset and still prevent rheumatic fever 1
• Do not prescribe shorter courses of penicillin or amoxicillin (less than 10 days) as this increases treatment failure risk 2

When to Consider Intramuscular Benzathine Penicillin G

• Use if adherence to oral therapy is unlikely 1
• Dose: 1.2 million units as a single intramuscular injection 1, 2
• Warm the medication to room temperature before injection to reduce pain 1

Monitoring and Follow-Up

Expected Clinical Course

• Patient becomes non-contagious after 24 hours of antibiotic therapy 1
• Symptoms should improve within 24-48 hours of starting treatment 1
• Re-evaluate if symptoms worsen after starting antibiotics or persist beyond 5 days of treatment 6

No Routine Follow-Up Testing Needed

• Post-treatment throat cultures or rapid tests are not recommended routinely 1, 2
• Only consider follow-up testing in special circumstances (e.g., history of rheumatic fever, persistent symptoms) 1

Common Pitfalls to Avoid

• Do not treat without confirming diagnosis with rapid antigen detection test (RADT) or throat culture 1, 2, 3
• Do not use broad-spectrum antibiotics when narrow-spectrum options (penicillin/amoxicillin) are effective 1, 2
• Do not prescribe tetracyclines, sulfonamides, or trimethoprim-sulfamethoxazole as they are ineffective against Group A streptococcus 1
• Do not routinely use corticosteroids - they provide minimal benefit (approximately 5 hours symptom reduction) with potential adverse effects 3
• Do not test or treat asymptomatic household contacts 1

Adjunctive Supportive Care

• Warm salt water gargles for symptom relief (if child is old enough to gargle) 3
• Ensure adequate hydration and rest 3
• Topical anesthetic lozenges may provide temporary relief 3