What is the recommended treatment for a patient with strep laryngitis?

Treatment of Strep Laryngitis

Treat strep laryngitis with penicillin V (250 mg four times daily or 500 mg twice daily) or amoxicillin (50 mg/kg once daily, maximum 1000 mg) for a full 10 days, as these remain the drugs of choice due to their proven efficacy, narrow spectrum, safety profile, and low cost. 1, 2

Confirming the Diagnosis First

• Document Group A Streptococcus (GAS) infection with either rapid antigen detection testing (RADT) or throat culture before initiating antibiotics, as clinical features alone cannot reliably distinguish bacterial from viral causes. 1, 3
• Laryngitis typically presents with hoarseness, which is actually more suggestive of a viral etiology rather than streptococcal infection—GAS pharyngitis classically causes sore throat, fever, tonsillar exudate, and cervical adenitis, but not prominent hoarseness or cough. 1, 4
• If hoarseness is the predominant symptom, consider that this may represent viral laryngitis rather than true streptococcal infection, and testing becomes even more critical before prescribing antibiotics. 1

First-Line Antibiotic Regimens

For patients without penicillin allergy:

• Penicillin V: 250 mg four times daily OR 500 mg twice daily for 10 days (adolescents and adults). 1, 2
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days is equally effective and often preferred due to once-daily dosing and better palatability. 1, 2
• Intramuscular benzathine penicillin G as a single dose (600,000 units if <27 kg; 1,200,000 units if ≥27 kg) ensures compliance when adherence to oral therapy is uncertain. 1, 2

Treatment for Penicillin-Allergic Patients

The type of penicillin allergy determines which alternative is safest:

Non-Immediate (Non-Anaphylactic) Penicillin Allergy

• First-generation cephalosporins are the preferred alternatives with strong, high-quality evidence. 1, 5
• Cephalexin 500 mg orally twice daily for 10 days (adults) or 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days (children). 1, 5
• Cefadroxil 1 gram orally once daily for 10 days (adults) or 30 mg/kg once daily (maximum 1 gram) for 10 days (children). 1, 5
• The cross-reactivity risk with first-generation cephalosporins is only 0.1% in patients with non-severe, delayed penicillin reactions, making them very safe. 5

Immediate/Anaphylactic Penicillin Allergy

• Patients with immediate hypersensitivity (anaphylaxis, angioedema, urticaria within 1 hour) must avoid ALL beta-lactam antibiotics, including cephalosporins, due to up to 10% cross-reactivity risk. 1, 5
• Clindamycin 300 mg orally three times daily for 10 days (adults) or 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days (children) is the preferred alternative. 1, 5, 2
• Clindamycin has only ~1% resistance among GAS in the United States and demonstrates high efficacy even in chronic carriers. 5, 2
• Azithromycin 500 mg orally once daily for 5 days (adults) or 12 mg/kg once daily (maximum 500 mg) for 5 days (children) is an acceptable alternative. 1, 5
• Clarithromycin 250 mg orally twice daily for 10 days (adults) or 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days (children) is also acceptable. 1, 5

Critical Treatment Duration Requirements

• A full 10-day course is essential for ALL antibiotics except azithromycin to achieve maximal pharyngeal eradication and prevent acute rheumatic fever. 1, 5, 2
• Azithromycin requires only 5 days due to its prolonged tissue half-life, making it the sole exception to the 10-day rule. 1, 5
• Shortening the course by even a few days dramatically increases treatment failure rates and risk of acute rheumatic fever, even if symptoms resolve in 3-4 days. 5, 2

Important Resistance Considerations

• Macrolide resistance (azithromycin, clarithromycin) among GAS is approximately 5-8% in the United States but varies geographically—some areas have much higher rates. 5, 4
• Clindamycin resistance remains very low at approximately 1%, making it more reliable than macrolides when beta-lactams cannot be used. 5, 2
• There is NO documented penicillin resistance in GAS anywhere in the world, which is why penicillin/amoxicillin remain first-line. 5

Common Pitfalls to Avoid

• Do not use cephalosporins if the patient had anaphylaxis, angioedema, or immediate urticaria to penicillin—the 10% cross-reactivity risk is too high. 5
• Do not prescribe broad-spectrum cephalosporins (cefdinir, cefixime, cefpodoxime) when narrow-spectrum first-generation agents (cephalexin, cefadroxil) are appropriate—they are more expensive and select for resistant flora. 5
• Do not assume all penicillin-allergic patients need macrolides or clindamycin—most can safely receive first-generation cephalosporins if the allergy was non-immediate. 5
• Do not prescribe shorter courses than recommended (except azithromycin's 5-day regimen)—this increases treatment failure and rheumatic fever risk. 5, 2

Adjunctive Symptomatic Treatment

• Acetaminophen or NSAIDs (such as ibuprofen) should be considered for moderate to severe symptoms or high fever as adjunctive therapy. 1, 5
• Aspirin must be avoided in children due to Reye syndrome risk. 1, 5
• Corticosteroids are NOT recommended as adjunctive therapy. 1, 5

Post-Treatment Follow-Up

• Routine follow-up throat cultures or RADT are NOT recommended for asymptomatic patients who have completed therapy. 1, 3
• Patients become non-contagious after 24 hours of appropriate antibiotic therapy. 3
• Reevaluate patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after starting treatment. 4