Amoxicillin 200 mg (20 mg/kg) Twice Daily for 10 Days
For a 1-year-old child (approximately 10 kg) with acute bacterial tonsillopharyngitis, prescribe amoxicillin 200 mg (20 mg/kg) orally twice daily for a complete 10-day course. 1
Dosing Rationale
Amoxicillin is the first-line antibiotic for Group A Streptococcal pharyngitis in young children because of proven efficacy, zero documented resistance worldwide, narrow antimicrobial spectrum, excellent safety profile, better palatability than penicillin V, and low cost. 1, 2
The recommended pediatric dose is 40–50 mg/kg/day divided into two doses (maximum 500 mg per dose), which for a 10 kg child equals approximately 200–250 mg twice daily. 1, 2
Twice-daily dosing improves adherence compared with three- or four-times-daily penicillin V schedules while maintaining identical efficacy. 1
Mandatory 10-Day Duration
A full 10-day course is absolutely required to achieve maximal pharyngeal eradication of Group A Streptococcus and to prevent acute rheumatic fever, even if symptoms resolve within 3–4 days. 1, 2
Shortening the course by even 2–3 days markedly increases treatment-failure rates and rheumatic fever risk. 1
The primary goal is prevention of acute rheumatic fever and suppurative complications (peritonsillar abscess, cervical lymphadenitis), not merely symptom relief—complete bacterial eradication is essential. 1
Alternatives for Penicillin Allergy
Non-Immediate (Delayed) Penicillin Allergy
- Cephalexin 200 mg (20 mg/kg) twice daily for 10 days is preferred; cross-reactivity risk with delayed reactions is only 0.1%. 1, 3
Immediate/Anaphylactic Penicillin Allergy
Clindamycin 70 mg (7 mg/kg) three times daily for 10 days is the optimal choice; resistance among US Group A Streptococcus is approximately 1%, and it achieves superior eradication even in chronic carriers. 1
Azithromycin 120 mg (12 mg/kg) once daily for 5 days is acceptable but less reliable due to 5–8% macrolide resistance in the United States. 1
Do not use cephalosporins in immediate/anaphylactic reactions because cross-reactivity can reach 10% with all β-lactam antibiotics. 1
Symptomatic Management
Acetaminophen or ibuprofen should be offered for fever, throat pain, or systemic discomfort. 1
Avoid aspirin in children due to Reye syndrome risk. 1
Corticosteroids are not recommended as adjunctive therapy. 1
Critical Pitfalls to Avoid
Do not shorten the antibiotic course below 10 days (except azithromycin's 5-day regimen); this dramatically increases treatment failure and rheumatic fever risk. 1
Do not prescribe trimethoprim-sulfamethoxazole; it fails to eradicate Group A Streptococcus in 20–25% of cases. 1
Reassess within 48–72 hours if no clinical improvement occurs; consider non-compliance, alternative diagnosis, or suppurative complications. 1, 2
Routine post-treatment throat cultures are unnecessary for asymptomatic children who completed therapy; reserve testing for special circumstances such as prior rheumatic fever. 1