What is the recommended treatment for a patient presenting with symptoms of a streptococcal infection, such as sore throat, fever, and swollen lymph nodes?

Treatment of Group A Streptococcal Pharyngitis

For confirmed Group A streptococcal pharyngitis, penicillin or amoxicillin for 10 days is the first-line treatment, as these narrow-spectrum antibiotics effectively prevent acute rheumatic fever while minimizing resistance and adverse effects. 1

Diagnosis Before Treatment

Testing is essential before prescribing antibiotics, as only 10% of adults and 15-35% of children with sore throat actually have streptococcal infection 2, 3:

• Do not test or treat patients with clear viral features: cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis, or diarrhea 1, 4
• Do test patients with sudden onset sore throat, fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough 1
• Rapid antigen detection test (RADT) is sufficient for adults; if negative, no further testing needed 1
• Children require throat culture if RADT is negative, due to higher risk of acute rheumatic fever 1
• Do not test children under 3 years unless special risk factors present (e.g., older sibling with confirmed infection), as streptococcal pharyngitis and rheumatic fever are rare in this age group 1

First-Line Antibiotic Treatment

For Penicillin-Tolerant Patients

Penicillin V or amoxicillin for 10 days is the gold standard 1, 5:

• Penicillin V: 250 mg orally 2-3 times daily for 10 days (children) or 500 mg 2-3 times daily (adults) 6, 5
• Amoxicillin: 50 mg/kg once daily (max 1000 mg) OR 25 mg/kg twice daily for 10 days 1, 6
• Benzathine penicillin G: Single intramuscular dose (600,000 units if <27 kg; 1,200,000 units if ≥27 kg) when compliance is a concern 1

The 10-day duration is critical—shorter courses fail to eradicate the organism and prevent rheumatic fever 5, 7. Group A streptococcus remains universally susceptible to penicillin 7, 8.

For Penicillin-Allergic Patients

Non-anaphylactic allergy (e.g., rash without respiratory/cardiovascular symptoms):

• First-generation cephalosporin for 10 days: cephalexin 500 mg every 6 hours orally 1, 2

Anaphylactic allergy (immediate hypersensitivity):

• Clindamycin: 300 mg orally 3 times daily for 10 days 1
• Clarithromycin: 250 mg twice daily for 10 days 1
• Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 1, 9

Critical caveat: Significant macrolide resistance exists in many U.S. regions, making azithromycin and clarithromycin less reliable 2. Clindamycin is preferred when available 1.

Symptomatic Management

• Acetaminophen or NSAIDs for pain and fever control 1, 4
• Never aspirin in children due to Reye syndrome risk 1, 4
• Corticosteroids are not recommended—they provide minimal benefit (approximately 5 hours symptom reduction) with potential adverse effects 1, 4

Treatment Failures and Recurrent Episodes

Single Recurrence Shortly After Treatment

If symptoms recur with positive testing within weeks of completing therapy 1:

• Retreat with any agent from Table 2 (penicillin, amoxicillin, cephalosporin, or macrolide) 1
• Consider intramuscular benzathine penicillin G to ensure compliance 1
• No need to retest after second course unless symptoms persist 1

Multiple Recurrent Episodes

Most patients with frequent positive tests are chronic carriers experiencing viral infections, not true recurrent streptococcal pharyngitis 1:

Clues suggesting carrier state rather than active infection 1:

• Symptoms more consistent with viral illness (cough, rhinorrhea)
• Positive cultures during asymptomatic periods
• Same strain isolated repeatedly over months

Carrier eradication is rarely needed except in special circumstances 1:

• Community outbreak of acute rheumatic fever or invasive disease
• Family history of acute rheumatic fever
• Excessive family anxiety about infections
• Tonsillectomy being considered solely for carriage

Regimens for carrier eradication (when indicated) 1:

• Clindamycin: 20-30 mg/kg/day in 3 doses for 10 days (max 300 mg/dose)
• Penicillin V plus rifampin: Penicillin V 50 mg/kg/day in 4 doses for 10 days PLUS rifampin 20 mg/kg/day for last 4 days (max 600 mg/day rifampin)
• Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses for 10 days (max 2000 mg/day)

Critical Pitfalls to Avoid

• Never prescribe antibiotics without confirming streptococcal infection—60% of patients with sore throat receive unnecessary antibiotics 2
• Never stop antibiotics early—the full 10-day course is essential to prevent acute rheumatic fever, even if symptoms resolve 5, 7
• Never use oral penicillin in severely ill patients with vomiting, gastric dilatation, or intestinal hypermotility, as absorption is unreliable 5
• Reevaluate urgently if symptoms worsen after 48-72 hours of appropriate antibiotics or persist beyond 5 days, as this suggests complications (peritonsillar abscess, Lemierre syndrome) or incorrect diagnosis 6, 2
• Do not routinely test or treat asymptomatic household contacts unless special circumstances exist 1

Rare but Serious Complications

Untreated or inadequately treated streptococcal pharyngitis can lead to life-threatening complications 10:

• Acute rheumatic fever: Primary reason for antibiotic treatment 7, 8
• Post-streptococcal glomerulonephritis: Can progress to pulmonary-renal syndrome with diffuse alveolar hemorrhage and rapidly progressive glomerulonephritis 10
• Suppurative complications: Peritonsillar abscess, retropharyngeal abscess, cervical lymphadenitis 1

These complications underscore why completing the full antibiotic course is non-negotiable, even when symptoms improve rapidly 5, 10.