What is the treatment for Streptococcal (Strep) pharyngitis?

From the Guidelines

Strep throat (streptococcal pharyngitis) is best treated with antibiotics, specifically penicillin or amoxicillin as first-line therapy. For adults, the recommended regimen is penicillin V 500 mg orally twice daily for 10 days, or amoxicillin 500 mg orally twice daily for 10 days 1. For children, amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days is preferred due to better taste and compliance 1. For patients with penicillin allergy, alternatives include cephalexin 500 mg twice daily for 10 days (if non-anaphylactic allergy), or for true penicillin allergy, azithromycin 500 mg on day 1 followed by 250 mg daily for 4 more days, or clindamycin 300 mg three times daily for 10 days 1. Some key points to consider when treating strep throat include:

• Completing the full course of antibiotics even if symptoms improve quickly, as this helps prevent complications like rheumatic fever and reduces symptom duration and contagiousness 1
• Using supportive care with acetaminophen or ibuprofen for pain and fever, warm salt water gargles, and adequate hydration to help manage symptoms 1
• Most patients improve within 24-48 hours of starting antibiotics and can return to school or work after 24 hours of antibiotic therapy when they're no longer contagious 1 It's also important to note that the diagnosis of strep throat should be established through a combination of clinical judgment and diagnostic test results, with the throat culture being the criterion standard 1. The treatment of strep throat is crucial in preventing complications such as acute rheumatic fever, which can lead to serious health problems, especially in developing countries 1. Overall, the treatment of strep throat should prioritize the use of antibiotics, such as penicillin or amoxicillin, and supportive care to manage symptoms and prevent complications.

From the FDA Drug Label

Pharyngitis/Tonsillitis caused by Streptococcus pyogenes NOTE: The usual drug of choice in the treatment and prevention of streptococcal infections, including the prophylaxis of rheumatic fever, is penicillin given by the intramuscular route Cefuroxime axetil for oral suspension is generally effective in the eradication of streptococci from the nasopharynx; however, substantial data establishing the efficacy of cefuroxime in the subsequent prevention of rheumatic fever are not available.

Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy. NOTE: Penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever.

The treatment for strep A pharyngitis is penicillin given by the intramuscular route, as it is the usual drug of choice in the treatment and prevention of streptococcal infections, including the prophylaxis of rheumatic fever 2 3.

• Cefuroxime axetil and azithromycin can be used as alternative treatments in certain cases, but they are not the first-line therapy.
• Cefuroxime axetil is generally effective in the eradication of streptococci from the nasopharynx, but there is limited data on its efficacy in preventing rheumatic fever 2.
• Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy, but susceptibility tests should be performed to ensure the bacteria are susceptible to azithromycin 3.

From the Research

Treatment Options for Strep A Pharyngitis

• Penicillin is the most commonly recommended treatment for group A streptococcal pharyngitis, with a 10-day course of treatment necessary to achieve a clinical and bacteriologic cure 4, 5, 6, 7
• The usually recommended penicillin V dose is 250 mg (400,000 IU) three times daily, although twice daily dosing is acceptable to some authorities if compliance is good 4
• Amoxicillin is equally effective and more palatable than penicillin, and can be used as an alternative treatment 5, 6, 8
• First-generation cephalosporins, such as cefpodoxime proxetil, are also effective in treating group A streptococcal pharyngitis, and may be superior to penicillin in eradicating the bacteria from the pharynx 4
• Erythromycin and other macrolide antibiotics can be used as alternative treatments in patients with penicillin allergy 5, 6, 7

Duration of Treatment

• A 10-day course of treatment is typically recommended for group A streptococcal pharyngitis, although some studies suggest that a 5-day course of treatment with certain antibiotics, such as cefpodoxime, may be effective 4, 8
• Once-daily amoxicillin therapy has been shown to be as effective as penicillin V therapy given three times a day for the treatment of group A streptococcal pharyngitis 8

Treatment Failure and Resistance

• Oral penicillin fails to eradicate group A streptococci from the pharynx in up to 17% of cases, and in some studies, 30% failure rates have been reported 4
• Increased group A beta-hemolytic streptococcus (GABHS) treatment failure with penicillin has been reported, and alternative treatments may be necessary in patients with penicillin allergy or treatment failure 5, 7