From the Guidelines
Penicillin V is the first-choice antibiotic for strep throat (streptococcal pharyngitis) and streptococcal laryngitis, with a typical adult dosage of 500 mg orally twice daily for 10 days, as it has a narrow spectrum and no reported resistance to Group A Streptococcus 1. The dosage for children is typically 250 mg twice daily (or weight-based dosing of 25-50 mg/kg/day divided into two doses) 1. It's crucial to complete the full 10-day course even if symptoms improve earlier to prevent complications like rheumatic fever. For patients with penicillin allergy, alternatives include:
- Amoxicillin (500 mg three times daily for adults)
- Azithromycin (500 mg on day 1, then 250 mg daily for 4 more days)
- Clindamycin (300 mg three times daily for 10 days) 1. Before starting antibiotics, it's best to confirm the diagnosis with a rapid strep test or throat culture, as most sore throats are viral and don't require antibiotics 1. Rest, adequate hydration, and over-the-counter pain relievers can help manage symptoms while the antibiotics work. It's also important to note that the treatment should be chosen based on factors such as bacteriologic and clinical efficacy, ease of adherence, cost, spectrum of activity, and potential side effects 1.
From the FDA Drug Label
In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) 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 (for the combined evaluable patient with documented GABHS): Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14 Day 30 Bacteriologic Eradication: Azithromycin 323/340 (95%) 255/330 (77%) Penicillin V 242/332 (73%) 206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin 336/343 (98%) 310/330 (94%) Penicillin V 284/338 (84%) 241/325 (74%)
The best antibiotic for strep throat/laryngitis is azithromycin, as it has been shown to be clinically and microbiologically statistically superior to penicillin in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) 2.
- Key points:
- Azithromycin has a higher bacteriologic eradication rate than penicillin at Day 14 and Day 30.
- Azithromycin has a higher clinical success rate than penicillin at Day 14 and Day 30.
- The recommended dose of azithromycin for children with pharyngitis/tonsillitis is 12 mg/kg once daily for 5 days 2.
From the Research
Antibiotic Treatment for Strep Throat/Laryngitis
- The recommended first-line antibiotics for strep throat are penicillin and amoxicillin, with a course of 10 days 3.
- First-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 3.
- Azithromycin and clarithromycin are not recommended due to significant resistance in some parts of the United States 3.
- Amoxicillin or penicillin are also recommended for children who are likely to have Group A Streptococcus (GAS) pharyngitis based on history or physical examination 4.
Diagnosis and Testing
- Clinical decision rules should be used to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear 3.
- A throat culture is recommended in children and adolescents after a negative rapid antigen test result 3.
- Symptoms such as fever, tonsillar exudate, cervical lymphadenitis, and patient ages of 3 to 15 years increase clinical suspicion of strep throat 3.