What are the treatment options for recurrent streptococcal pharyngitis after treatment with Penicillin V (penicillin)

From the Guidelines

For recurrent strep throat after penicillin V treatment, the recommended approach is to switch to a different antibiotic, with Clindamycin (20–30 mg/kg/day in 3 equally divided doses for 10 days) being a suitable option, as indicated by the Infectious Diseases Society of America guidelines 1. When considering treatment for recurrent strep throat, it's essential to differentiate between true recurrent infections and chronic carriage of Group A Streptococci (GAS). The guidelines suggest that clinicians should be alert to the possibility that patients with recurrent episodes of pharyngitis may be experiencing multiple episodes of bona fide streptococcal pharyngitis at close intervals, but also consider the possibility of chronic pharyngeal GAS carriage with repeated viral infections 1. Some key points to consider in the management of recurrent strep throat include:

• The use of alternative antibiotics such as amoxicillin-clavulanic acid (40 mg amoxicillin/kg/day in 3 doses for 10 days) or intramuscular benzathine penicillin G (600,000 U for <27 kg and 1,200,000 U for ≥27 kg) with or without oral rifampin (20 mg/kg/day in 2 doses for 4 days) 1.
• The importance of completing the full course of the new antibiotic, even if symptoms improve quickly.
• The consideration of throat culture and sensitivity testing to guide further treatment if symptoms persist after a second antibiotic course.
• The potential role of tonsillectomy in patients with multiple recurrences despite appropriate antibiotic therapy, although this is not recommended solely to reduce the frequency of GAS pharyngitis 1.
• The need to test family members if they have symptoms, as household transmission can contribute to recurrence.

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 Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates Approximately 1% of azithromycin-susceptible S pyogenes isolates were resistant to azithromycin following therapy.

Treatment for recurrent strep after penicillin V treatment: Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy, and it has been shown to be clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30. However, approximately 1% of azithromycin-susceptible S pyogenes isolates were resistant to azithromycin following therapy.

• Key points:
  • Azithromycin is an alternative to first-line therapy for pharyngitis/tonsillitis caused by Streptococcus pyogenes.
  • Azithromycin has been shown to be clinically and microbiologically statistically superior to penicillin.
  • Resistance to azithromycin may occur in approximately 1% of azithromycin-susceptible S pyogenes isolates. 2

From the Research

Treatment Options for Recurrent Strep After Penicillin V Treatment

• The treatment of recurrent strep after penicillin V treatment can be approached with alternative antibiotics, as evidenced by several studies 3, 4, 5, 6, 7.
• Azithromycin has been compared to penicillin V in the treatment of acute group A streptococcal pharyngitis, with similar clinical efficacy but lower bacteriologic eradication rates 3.
• Amoxicillin has been shown to be effective in the treatment of group A beta-haemolytic streptococcal pharyngitis, with once-daily dosing being as effective as penicillin V three times a day 4, 7.
• A 6-day course of amoxicillin has been compared to a 10-day course of penicillin V, with similar efficacy and safety profiles in adults with streptococcal tonsillitis 5.
• A systematic review of different antibiotic treatments for group A streptococcal pharyngitis found that cephalosporins, macrolides, and carbacephem may be effective alternatives to penicillin, but the evidence is largely uncertain due to methodological limitations and heterogeneity between studies 6.

Alternative Antibiotics

• Cephalosporins may have a lower risk of clinical relapse compared to penicillin, but the evidence is uncertain 6.
• Macrolides, such as azithromycin, may have similar efficacy to penicillin in the treatment of group A streptococcal pharyngitis, but with a higher risk of adverse events 3, 6.
• Carbacephem may be more effective than penicillin in symptom resolution, but the evidence is limited 6.
• Amoxicillin, given once daily, may be non-inferior to penicillin V given twice daily in the treatment of group A beta-haemolytic streptococcal pharyngitis 7.