What are the care instructions for a patient diagnosed with strep throat?

Strep Throat Care Instructions

For confirmed strep throat, complete a full 10-day course of antibiotics (except azithromycin which requires only 5 days), use acetaminophen or ibuprofen for symptom relief, and return to school/work 24 hours after starting antibiotics once fever-free. 1, 2

Antibiotic Treatment

First-Line Therapy

• Penicillin or amoxicillin remains the drug of choice due to proven efficacy, narrow spectrum, safety, and low cost, with no documented penicillin resistance in Group A Streptococcus anywhere in the world 1, 3
• Adults: Amoxicillin 500 mg orally twice daily OR penicillin V 500 mg orally twice daily for 10 days 1, 2
• Children: Amoxicillin 50 mg/kg once daily (maximum 1,000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 4, 2
• Alternatively, a single intramuscular injection of benzathine penicillin G (600,000 units for children <27 kg; 1,200,000 units for ≥27 kg or adults) can be given when compliance with oral medication is uncertain 1, 4

Critical Treatment Duration

• A full 10-day course is mandatory for all antibiotics except azithromycin to achieve maximal pharyngeal eradication and prevent acute rheumatic fever 1, 4, 2
• Shortening the course by even a few days dramatically increases treatment failure rates and rheumatic fever risk, even if symptoms resolve in 3-4 days 1, 3
• Treatment should continue for a minimum of 48-72 hours beyond when the patient becomes asymptomatic 2

For Penicillin-Allergic Patients

Non-Anaphylactic Allergy (delayed rash, no breathing difficulty):

• First-generation cephalosporins are preferred: cephalexin 500 mg twice daily (adults) or 20 mg/kg/dose twice daily (children) for 10 days 1, 3
• Cross-reactivity risk is only 0.1% in patients with non-severe, delayed penicillin reactions 3

Immediate/Anaphylactic Allergy (hives, angioedema, breathing difficulty within 1 hour):

• Avoid all cephalosporins due to up to 10% cross-reactivity risk 1, 3
• Clindamycin is the preferred choice: 300 mg three times daily (adults) or 7 mg/kg/dose three times daily (children, maximum 300 mg/dose) for 10 days 1, 3
• Clindamycin has only ~1% resistance among Group A Streptococcus in the United States and demonstrates high efficacy even in chronic carriers 1, 3
• Alternative macrolides: azithromycin 500 mg once daily for 5 days (adults) or 12 mg/kg once daily for 5 days (children), though macrolide resistance is 5-8% in the United States 1, 3

Symptomatic Treatment

Pain and Fever Management

• Use acetaminophen or NSAIDs (ibuprofen) for moderate to severe symptoms or high fever 1, 3, 4
• Never give aspirin to children due to risk of Reye syndrome 1, 3, 4
• Corticosteroids are not recommended as adjunctive therapy 1, 3

General Supportive Care

• Encourage adequate fluid intake to prevent dehydration 5
• Soft foods and cold liquids may help soothe throat pain 5
• Rest until fever resolves and energy returns 6

When to Return to School/Work

• Patients can return 24 hours after starting antibiotics, once fever-free without fever-reducing medications 6, 7
• Early antibiotic treatment reduces symptom duration to less than 24 hours in most cases and limits disease spread 6

Follow-Up and Warning Signs

Routine Follow-Up

• Do not obtain routine post-treatment throat cultures or rapid tests in asymptomatic patients who have completed therapy 1
• Follow-up testing should only be considered in special circumstances, such as patients with a history of rheumatic fever 1, 3

When to Seek Immediate Medical Attention

• Worsening symptoms after 48-72 hours of appropriate antibiotic therapy 7
• Symptoms lasting 5 days after starting treatment 7
• Difficulty breathing or swallowing 5
• Severe neck swelling or inability to open mouth fully 5
• Signs of dehydration (decreased urination, extreme thirst, dizziness) 5

Treatment Failures and Recurrent Infections

Single Treatment Failure

• If symptoms persist or recur shortly after completing a 10-day course, consider compliance issues first 1
• For questionable compliance, intramuscular benzathine penicillin G should be considered 1
• For confirmed compliance failure, clindamycin or amoxicillin-clavulanate may be more effective at eradicating persistent streptococci 1

Multiple Recurrent Episodes

• Most patients with frequent positive throat cultures are chronic carriers experiencing repeated viral infections, not true recurrent strep infections 1, 8
• Chronic carriers generally do not require treatment, as they are unlikely to spread infection or develop complications 1, 3
• Consider tonsillectomy only if 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 8, 7

Common Pitfalls to Avoid

• Do not stop antibiotics early even if feeling better—this increases treatment failure and rheumatic fever risk 1, 3, 4
• Do not use trimethoprim-sulfamethoxazole (Bactrim) for strep throat—it has 50% resistance and does not eradicate Group A Streptococcus 3, 4
• Do not assume all penicillin-allergic patients need to avoid cephalosporins—only those with immediate/anaphylactic reactions should avoid them 1, 3
• Do not prescribe antibiotics without diagnostic confirmation (rapid antigen test or throat culture) 1, 4, 7

Prevention of Complications

• The primary goal of antibiotic treatment is preventing acute rheumatic fever and suppurative complications (peritonsillar abscess, cervical lymphadenitis, mastoiditis), not just symptom relief 1, 4
• Therapy can be safely postponed up to 9 days after symptom onset and still prevent acute rheumatic fever 3
• Adequate bacterial eradication through complete antibiotic courses is essential for preventing these serious complications 1, 4