From the Guidelines
Penicillin V potassium is the first-line medication for treating strep pharyngitis, with a recommended regimen of 250 mg orally two to three times daily for children and 500 mg orally two to three times daily for adolescents and adults, for a total of 10 days, as supported by the Infectious Diseases Society of America guidelines 1. The choice of antibiotic is crucial in treating strep pharyngitis, and the guidelines recommend penicillin or amoxicillin as the preferred treatment due to their narrow spectrum of activity, infrequency of adverse reactions, and modest cost 1. For patients with penicillin allergy, alternatives include:
- Amoxicillin (50 mg/kg once daily, maximum 1000 mg, for 10 days)
- First-generation cephalosporins like cephalexin (if no history of anaphylaxis to penicillin)
- Macrolides such as azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days) or clindamycin (7 mg/kg three times daily, maximum 300 mg per dose, for 10 days) for patients with severe penicillin allergy 1. It is essential to complete the full course of antibiotics even if symptoms improve to ensure eradication of the bacteria and prevent complications like rheumatic fever or post-streptococcal glomerulonephritis. Key considerations in selecting a treatment regimen include bacteriologic and clinical efficacy, ease of adherence, cost, spectrum of activity, and potential side effects 1. The American Heart Association also recommends penicillin or amoxicillin as the first-line treatment for strep pharyngitis, with alternative options for patients with penicillin allergy 1. Overall, the guidelines emphasize the importance of accurate diagnosis and appropriate antimicrobial therapy to prevent complications and reduce the risk of rheumatic fever 1.
From the FDA Drug Label
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 first-line medications to treat strep pharyngitis are:
- Penicillin by the intramuscular route, which is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever. Azithromycin is often used as an alternative to first-line therapy in individuals who cannot use first-line therapy 2.
From the Research
First-Line Medications for Strep Pharyngitis
- Penicillin is considered the treatment of choice for strep pharyngitis due to its cost, narrow spectrum of activity, and effectiveness 3, 4, 5.
- Amoxicillin is equally effective as penicillin and is more palatable, making it a suitable alternative 3, 4, 5.
- First-generation cephalosporins are recommended for patients with non-anaphylactic allergies to penicillin 3, 4, 5.
- Other options for patients with penicillin allergy include clindamycin and macrolide antibiotics 5.
Comparison of Antibiotics
- Cephalosporins versus penicillin: there is low-certainty evidence that cephalosporins may have a slightly higher rate of symptom resolution, but the difference is not significant 6.
- Macrolides versus penicillin: there is low-certainty evidence that macrolides may have a similar rate of symptom resolution as penicillin 6.
- Azithromycin versus amoxicillin: there is very low-certainty evidence that azithromycin may have a similar rate of symptom resolution as amoxicillin, but with more adverse events 6.
- Carbacephem versus penicillin: there is low-certainty evidence that carbacephem may be more effective than penicillin for symptom resolution in adults and children 6.