What is the best antibiotic (abx) for acute pharyngitis (po)?

From the Guidelines

For acute pharyngitis, the best antibiotic choice is typically penicillin or amoxicillin for those non-allergic to these agents, with a recommended duration of 10 days. The recommended dose for penicillin V is 250 mg twice or three times daily for children, and 250 mg four times daily or 500 mg twice daily for adolescents and adults 1. For amoxicillin, the recommended dose is 50 mg/kg once daily (max = 1000 mg) or 25 mg/kg twice daily (max = 500 mg) for 10 days 1. This antibiotic is preferred because it provides coverage against the most common causative organism, Group A Streptococcus, and has a narrow spectrum of activity, infrequency of adverse reactions, and modest cost.

• For patients with penicillin allergies, alternatives include:
  • Cephalexin, 20 mg/kg/dose twice daily (max = 500 mg/dose) for 10 days 1
  • Cefadroxil, 30 mg/kg once daily (max = 1 g) for 10 days 1
  • Clindamycin, 7 mg/kg/dose three times daily (max = 300 mg/dose) for 10 days 1
  • Azithromycin, 12 mg/kg once daily (max = 500 mg) for 5 days 1
• It is essential to note that antimicrobial resistance has not been a significant issue in the treatment of Group A streptococcal pharyngitis in the United States, with no clinical isolate of Group A Streptococcus documented to be resistant to penicillin 1.
• Accurate diagnosis of streptococcal pharyngitis followed by appropriate antimicrobial therapy is crucial for preventing acute rheumatic fever, suppurative complications, and improving clinical symptoms and signs 1.
• The choice of antibiotic should be based on the patient's allergy history, the severity of the infection, and the potential for resistance, with penicillin or amoxicillin being the first-line treatment for most cases, as recommended by the Infectious Diseases Society of America 1.

From the FDA Drug Label

Pediatric Patients Azithromycin for oral suspension can be taken with or without food. The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute otitis media is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days or 10 mg/kg as a single dose on the first day followed by 5 mg/kg/day on Days 2 through 5. The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with acute bacterial sinusitis is 10 mg/kg once daily for 3 days. The recommended dose of azithromycin for oral suspension for the treatment of pediatric patients with community-acquired pneumonia is 10 mg/kg as a single dose on the first day followed by 5 mg/kg on Days 2 through 5. The recommended dose of azithromycin for children with pharyngitis/tonsillitis is 12 mg/kg once daily for 5 days.

The best antibiotic for acute pharyngitis/tonsillitis is azithromycin, with a recommended dose of 12 mg/kg once daily for 5 days 2. For acute otitis media, the recommended dose of azithromycin is 30 mg/kg given as a single dose or 10 mg/kg once daily for 3 days 2. For acute bacterial sinusitis, the recommended dose of azithromycin is 10 mg/kg once daily for 3 days 2. For community-acquired pneumonia, the recommended dose of azithromycin is 10 mg/kg as a single dose on the first day followed by 5 mg/kg on Days 2 through 5 2.

• Key points:
  • Azithromycin is effective against various bacterial infections, including acute otitis media, acute bacterial sinusitis, community-acquired pneumonia, and pharyngitis/tonsillitis.
  • The recommended dose of azithromycin varies depending on the type of infection and the patient's weight.
  • Azithromycin can be taken with or without food.
• Main considerations:
  • The effectiveness of azithromycin in treating acute pharyngitis/tonsillitis, acute otitis media, acute bacterial sinusitis, and community-acquired pneumonia has been established in clinical trials 2.
  • The safety of re-dosing azithromycin in pediatric patients who vomit after receiving 30 mg/kg as a single dose has not been established 2.

From the Research

Best Antibiotics for Acute Pharyngitis

• Penicillin V and amoxicillin are the first-line options for treating acute pharyngitis caused by group A β-hemolytic Streptococcus (GABHS) 3, 4, 5
• In cases of penicillin allergy, first-generation cephalosporins are a suitable choice 3, 4, 5
• For patients with beta-lactam allergy, clindamycin or macrolides could be considered according to local resistance rates 3
• A 10-day course of antibiotics is recommended if the prevention of acute rheumatic fever (ARF) is the primary goal, while some guidelines suggest a 5-7 day course for symptomatic cure 3, 4

Diagnosis and Treatment Approach

• The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 5
• Rapid antigen detection tests and throat cultures can be used with clinical findings to identify the inciting organism 5, 6
• Physicians should exercise restraint in antibiotic initiation for pharyngitis, as restraint does not delay recovery or increase the risk of S pyogenes infections 6

Considerations for Specific Patient Groups

• In children and adolescents, a throat culture is recommended after a negative rapid antigen test result 4
• For patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment, reevaluation is necessary 4