What is the recommended treatment for a child diagnosed with strep throat?

Treatment of Strep Throat in Children

For children with confirmed strep throat, penicillin or amoxicillin for 10 days is the first-line treatment, with amoxicillin preferred due to better compliance and equal efficacy. 1, 2

First-Line Antibiotic Therapy

• Amoxicillin is the preferred first-line agent at 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days. 1, 2
• Penicillin V is an acceptable alternative at 250 mg 2-3 times daily for children <27 kg (60 lb) or 500 mg 2-3 times daily for children ≥27 kg (60 lb), also for 10 days. 1
• Benzathine penicillin G as a single intramuscular injection (600,000 U for children <27 kg; 1,200,000 U for children ≥27 kg) ensures compliance and remains preferred in settings where follow-up is unreliable or compliance with oral medication cannot be assured. 1, 3

Critical Treatment Duration

• The full 10-day course is essential to achieve maximal pharyngeal eradication of Group A Streptococcus and prevent acute rheumatic fever, which remains the primary goal of treatment. 1, 2
• Treatment can be safely initiated up to 9 days after symptom onset and still prevent acute rheumatic fever. 4, 2
• Shortening the antibiotic course below 10 days (except for azithromycin's 5-day regimen) dramatically increases treatment failure rates and risk of rheumatic fever. 4, 2

Treatment for Penicillin-Allergic Children

Non-Immediate (Non-Anaphylactic) Penicillin Allergy

• First-generation cephalosporins are the preferred alternatives with strong, high-quality evidence supporting their efficacy. 1, 4, 2
• Cephalexin 20 mg/kg per dose twice daily (maximum 500 mg/dose) for 10 days. 1, 4
• Cefadroxil 30 mg/kg once daily (maximum 1 gram) for 10 days. 1, 4
• Cross-reactivity risk with first-generation cephalosporins is only 0.1% in patients with non-severe, delayed penicillin reactions. 4

Immediate/Anaphylactic Penicillin Allergy

• All beta-lactam antibiotics must be avoided due to up to 10% cross-reactivity risk in patients with immediate hypersensitivity reactions (anaphylaxis, angioedema, respiratory distress, or urticaria within 1 hour). 1, 4, 2
• Clindamycin is the preferred choice at 7 mg/kg per dose three times daily (maximum 300 mg/dose) for 10 days, with approximately 1% resistance rate among Group A Streptococcus in the United States. 1, 4, 2
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days is an acceptable alternative, though macrolide resistance is 5-8% in the United States. 1, 4, 2
• Clarithromycin 7.5 mg/kg per dose twice daily (maximum 250 mg/dose) for 10 days is also acceptable, with similar resistance concerns as azithromycin. 1, 4

Diagnostic Confirmation Required

• Laboratory confirmation through rapid antigen detection test (RADT) or throat culture is essential before initiating antibiotics. 1, 2, 5
• A positive RADT is diagnostic and requires no backup culture. 2
• A negative RADT must be backed up by throat culture in children and adolescents to ensure maximal sensitivity, as RADTs miss 10-20% of true strep infections. 1, 2
• In adults, a negative RADT alone is sufficient without backup culture due to lower disease prevalence and extremely low rheumatic fever risk. 1

Adjunctive Symptomatic Therapy

• Ibuprofen or acetaminophen are recommended for relief of acute sore throat symptoms, moderate to severe pain, or high fever. 1, 4, 2
• Aspirin must be avoided in children due to the risk of Reye syndrome. 4, 2
• Corticosteroids are not recommended as adjunctive therapy. 1, 4

Critical Pitfalls to Avoid

• Do not prescribe antibiotics based on clinical symptoms alone without laboratory confirmation—this leads to overuse of antibiotics, as only 20-30% of pharyngitis cases in children are actually strep. 6, 5
• Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions due to the 10% cross-reactivity risk. 4, 2
• Do not use trimethoprim-sulfamethoxazole (Bactrim) for strep throat due to high resistance rates (50%) and lack of efficacy. 4
• Do not routinely perform follow-up throat cultures in asymptomatic patients who have completed appropriate antibiotic therapy—this does not distinguish between carrier state and active infection. 6
• Do not test or treat asymptomatic household contacts prophylactically, even with a history of recurrent infections—up to one-third of households include asymptomatic GAS carriers. 6

Special Considerations

• Children under 3 years rarely have Group A streptococcal pharyngitis and generally should not be tested or treated. 6
• Early treatment can reduce symptom duration to less than 24 hours, decrease suppurative complications, and limit disease spread. 3
• Cephalosporins as a class may provide somewhat higher bacteriologic eradication rates than penicillin, with some studies showing 5-day courses of certain cephalosporins (cefdinir, cefpodoxime, cefuroxime) to be effective, though 10-day courses remain standard in most guidelines. 5, 7, 8