What is the recommended treatment for a pediatric patient with strep throat?

Treatment for Strep Throat in Pediatric Patients

Penicillin or amoxicillin for 10 days is the first-line treatment for streptococcal pharyngitis in children, with amoxicillin preferred in younger children due to better palatability and proven superior efficacy at appropriate dosing. 1, 2

Confirm Diagnosis Before Treatment

• Always confirm the diagnosis with rapid antigen detection test (RADT) before initiating antibiotics 2
• A positive RADT is diagnostic and does not require backup throat culture 2
• A negative RADT in children and adolescents must be followed by a throat culture to avoid missing true infections 1, 2
• Do not routinely test children under 3 years unless specific risk factors are present (e.g., older sibling with confirmed strep infection), as strep pharyngitis and rheumatic fever are rare in this age group 3

First-Line Antibiotic Regimens (Non-Allergic Patients)

For children without penicillin allergy, choose one of the following:

• Oral amoxicillin: 50 mg/kg once daily (maximum 1,000 mg) for 10 days 1, 2, 4

  • Alternative dosing: 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 4
  • Amoxicillin is superior to standard-dose penicillin V for both clinical cure (87.9% vs 70.9%) and bacteriologic cure (79.3% vs 54.5%) 5
  • Better palatability makes it ideal for younger children 1, 6

• Oral penicillin V: 250 mg two or three times daily for 10 days 1, 2

  • Despite being the historical gold standard, penicillin V may have lower efficacy due to inadequate dosing in some regimens 5

• Intramuscular benzathine penicillin G (single dose): 1, 2

  • 600,000 units for children <27 kg
  • 1,200,000 units for children ≥27 kg
  • Use this option when compliance with oral therapy is questionable 1, 7

Treatment for Penicillin-Allergic Patients

For non-anaphylactic (Type IV) penicillin allergy:

• First-generation cephalosporins (e.g., cephalexin): 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 1, 2
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1
• Avoid cephalosporins in patients with immediate (Type I) hypersensitivity reactions to penicillin 1

For immediate-type (anaphylactic) penicillin allergy:

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 2
• Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1, 2
• Important caveat: Significant resistance to azithromycin and clarithromycin exists in some U.S. regions, making these less reliable options 8

Duration and Timing

• The standard 10-day course is mandatory to ensure complete eradication and prevent rheumatic fever 1, 2, 7
• Shorter courses with cephalosporins have been studied but are not recommended as first-line due to the proven efficacy and safety of the 10-day penicillin/amoxicillin regimen 1
• Children must complete 24 hours of antibiotics before returning to school or daycare, as 36% of patients still have positive cultures the morning after starting treatment 9

Adjunctive Symptomatic Treatment

• Use acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1, 2
• Never use aspirin in children due to the risk of Reye syndrome 1, 2, 3
• Do not use corticosteroids for routine treatment of streptococcal pharyngitis 1, 2

Common Pitfalls to Avoid

• Do not treat without confirming diagnosis through testing—clinical features alone cannot reliably distinguish bacterial from viral pharyngitis 2
• Do not prescribe broad-spectrum antibiotics when narrow-spectrum options (penicillin/amoxicillin) are effective 2
• Do not perform routine post-treatment throat cultures in asymptomatic patients 1, 2, 7
• Do not use inadequate dosing of penicillin V—the perception of declining penicillin effectiveness may be due to underdosing rather than true resistance 5
• Avoid treating children under 3 years routinely, as strep pharyngitis is uncommon and rheumatic fever is extremely rare in this age group 3

When to Reevaluate

• Reevaluate patients with worsening symptoms after appropriate antibiotic initiation or symptoms lasting 5 days after starting treatment 8
• Consider whether the patient is a chronic carrier experiencing viral infections rather than true recurrent strep infections 1, 7
• For recurrent infections, consider retreatment with the same agent, intramuscular benzathine penicillin G if compliance is questionable, or alternative regimens for chronic carriers 7