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

Treatment of Streptococcal Pharyngitis in Pediatric Patients

Penicillin or amoxicillin for 10 days is the first-line treatment for pediatric patients with confirmed strep throat, based on proven efficacy, safety, narrow spectrum, and low cost. 1, 2

Diagnostic Confirmation Required Before Treatment

• Testing is mandatory - throat swab with rapid antigen detection test (RADT) and/or culture must confirm Group A Streptococcus (GAS) before initiating antibiotics, as clinical features alone cannot reliably distinguish bacterial from viral pharyngitis 1, 2

• In children and adolescents, negative RADTs require backup throat culture due to test sensitivity of only 80-90%, meaning 10-20% of true infections are missed 1, 2

• Positive RADTs are diagnostic and do not require confirmation with culture due to high specificity (>95%) 1

• Do not test children under 3 years old unless special risk factors exist (such as an older sibling with confirmed GAS infection), as strep pharyngitis and acute rheumatic fever are rare in this age group 1, 2

• Do not test when viral features are present - cough, rhinorrhea, hoarseness, conjunctivitis, or oral ulcers strongly suggest viral etiology and testing should be avoided 1

First-Line Antibiotic Treatment (Non-Allergic Patients)

For children ≥3 months and <40 kg:

• Amoxicillin 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, 3
• Penicillin V 250 mg two or three times daily for 10 days 1, 2

For adolescents and adults:

• Amoxicillin 500 mg twice daily OR 250 mg three times daily for 10 days 1, 3
• Penicillin V 250 mg four times daily OR 500 mg twice daily for 10 days 1

Intramuscular option:

• Benzathine penicillin G single dose: 600,000 units for patients <27 kg; 1,200,000 units for patients ≥27 kg 1, 2

The 10-day duration is critical to eradicate the organism and prevent acute rheumatic fever, which can be prevented if treatment begins within 9 days of symptom onset 1, 3

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy:

• First-generation cephalosporin (e.g., cephalexin) 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 1, 2, 4

For immediate-type hypersensitivity/anaphylactic allergy:

• Clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 2, 4
• Clarithromycin 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1, 2, 4
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 2, 4

Note that macrolide resistance varies geographically and should be considered when selecting azithromycin or clarithromycin 4

Adjunctive Symptomatic Treatment

• Acetaminophen or ibuprofen should be used for moderate to severe symptoms or high fever 1, 2

• Never use aspirin in children due to risk of Reye syndrome 1, 2

• Corticosteroids are not recommended for routine treatment of strep pharyngitis 1, 2

What NOT to Do: Critical Pitfalls

• Do not treat without laboratory confirmation - up to 70% of sore throats are viral, and clinical appearance (including white patches and exudate) cannot reliably distinguish bacterial from viral causes 1, 5

• Do not perform routine post-treatment cultures in asymptomatic patients after completing appropriate antibiotic therapy, as positive tests may simply reflect carrier status rather than active infection 1, 5

• Do not test or treat asymptomatic household contacts - up to one-third of households have asymptomatic GAS carriers, and prophylactic antibiotics have not been shown to reduce subsequent infections 1, 5

• Do not use broad-spectrum antibiotics when narrow-spectrum penicillin or amoxicillin is effective, as this contributes to antibiotic resistance 1, 2

Special Considerations for Recurrent Episodes

• Distinguish true recurrent infections from chronic carriers with viral pharyngitis - patients with multiple positive cultures at short intervals may be GAS carriers experiencing repeated viral infections rather than true bacterial reinfections 1, 4

• Confirm each episode with RADT or culture before treating, as chronic carriers do not require treatment unless specific circumstances exist (outbreak situations, personal/family history of acute rheumatic fever, or excessive anxiety) 1, 4

• Consider tonsillectomy only for severe recurrent cases meeting specific frequency criteria: ≥7 episodes in 1 year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years, with each episode properly documented 4