What is the recommended antibiotic course for Streptococcus A (Strep A) infection?

From the Guidelines

The standard antibiotic course for strep throat (Group A Streptococcus) is typically 10 days of oral penicillin, with amoxicillin being a recommended option at 50 mg/kg once daily (max = 1000 mg) for 10 days, as stated in the 2012 update by the Infectious Diseases Society of America 1. When considering treatment options, it's essential to note that the choice of antibiotic depends on the patient's allergy status and other factors.

• For individuals without penicillin allergy, options include:
  • Penicillin V, oral, with a dose of 250 mg twice daily or 3 times daily for children and 250 mg 4 times daily or 500 mg twice daily for adolescents and adults, for 10 days 1.
  • Amoxicillin, oral, with a dose of 50 mg/kg once daily (max = 1000 mg) for 10 days 1.
• For individuals with penicillin allergy, alternatives include:
  • Cephalexin, oral, with a dose of 20 mg/kg/dose twice daily (max = 500 mg/dose) for 10 days 1.
  • Azithromycin, oral, with a dose of 12 mg/kg once daily (max = 500 mg) for 5 days, although resistance to this agent is well-known and varies geographically and temporally 1. It's crucial to complete the entire course of antibiotics even if symptoms improve within a few days, as stopping early can lead to recurrence and complications like rheumatic fever or kidney inflammation, as highlighted in the guideline 1. Treatment typically brings symptom relief within 24-48 hours, and while taking antibiotics, it's recommended to stay hydrated, rest adequately, and use over-the-counter pain relievers like acetaminophen or ibuprofen for throat pain and fever. The full course is necessary to completely eradicate the bacteria from the throat, preventing both the spread of infection to others and the development of serious complications, such as acute rheumatic fever, which can lead to acquired heart disease in children, especially in areas like India, sub-Saharan Africa, and parts of Australia and New Zealand 1.

From the FDA Drug Label

It is recommended that there be at least 10 days’ treatment for any infection caused by Streptococcus pyogenes to prevent the occurrence of acute rheumatic fever. Treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic, or evidence of bacterial eradication has been obtained

The recommended antibiotic course for Strep A (Streptococcus pyogenes) is at least 10 days to prevent the occurrence of acute rheumatic fever.

• The treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic, or evidence of bacterial eradication has been obtained 2

From the Research

Strep A Antibiotic Course

• The recommended antibiotic course for Strep A pharyngitis is typically 10 days of oral penicillin or amoxicillin 3, 4.
• Penicillin is the first-line treatment due to its low cost, narrow spectrum of activity, and effectiveness 5, 3, 4.
• Amoxicillin is equally effective and more palatable than penicillin 3, 4.
• For patients with penicillin allergy, erythromycin and first-generation cephalosporins are alternative options 3, 4.
• Short-course antibiotic treatment (≤5 days) may be as effective as long-course treatment (≥7 days) for early clinical cure and bacterial eradication, but the evidence is not conclusive 6.
• Cephalosporins may be more effective than penicillin for clinical relapse, but the number needed to treat to benefit is high 5, 6, 7.
• Macrolides and cephalosporins have a higher risk of adverse events and should be used judiciously 6, 7.
• The choice of antibiotic should be based on the patient's medical history, allergy status, and local resistance patterns 3, 4.

Duration of Antibiotic Treatment

• The standard duration of antibiotic treatment for Strep A pharyngitis is 10 days 3, 4.
• Short-course treatment (≤5 days) may be considered in certain cases, but the evidence is not conclusive 6.
• Long-course treatment (≥7 days) may be necessary in some cases, such as in patients with recurrent infections or those who do not respond to short-course treatment 6.

Special Considerations

• Patients with penicillin allergy should be treated with alternative antibiotics, such as erythromycin or first-generation cephalosporins 3, 4.
• Patients with a history of recurrent Strep A infections may require longer courses of antibiotic treatment or alternative treatments, such as tonsillectomy 3, 4.
• The use of antibiotics should be guided by clinical judgment and local resistance patterns 3, 4.