What is the treatment for an adult with streptococcal (strep) pharyngitis?

From the Guidelines

For an adult with strep pharyngitis, the recommended treatment is oral penicillin V 250 mg 4 times daily or 500 mg twice daily for 10 days, as this regimen has been shown to be effective in eradicating the organism from the pharynx and preventing complications 1.

Treatment Options

The treatment options for strep pharyngitis in adults include:

• Penicillin V, oral: 250 mg 4 times daily or 500 mg twice daily for 10 days, which is the recommended drug of choice for those non-allergic to these agents 1
• Amoxicillin, oral: 50 mg/kg once daily (max = 1000 mg) or 25 mg/kg (max = 500 mg) twice daily for 10 days, which is an alternative to penicillin V 1
• Benzathine penicillin G, intramuscular: 1 200 000 U for individuals ≥27 kg, which is a single-dose treatment option 1

Considerations for Penicillin-Allergic Patients

For patients with a penicillin allergy, alternative treatment options include:

• Cephalexin, oral: 20 mg/kg/dose twice daily (max = 500 mg/dose) for 10 days, which is a first-generation cephalosporin that can be used in patients who are not anaphylactically sensitive to penicillin 1
• Azithromycin, oral: 12 mg/kg once daily (max = 500 mg) for 5 days, which is a macrolide antibiotic that can be used in patients with a penicillin allergy 1

Additional Recommendations

In addition to antibiotic treatment, patients with strep pharyngitis should:

• Rest and stay hydrated to help manage symptoms
• Use over-the-counter pain relievers like acetaminophen or ibuprofen to help manage pain and fever
• Gargle with warm salt water (1/4 teaspoon salt in 8 ounces of warm water) to provide throat relief
• Complete the full antibiotic course even if symptoms improve, and can return to work or school 24 hours after starting antibiotics when no longer contagious
• Seek medical attention if symptoms worsen or don't improve after 3-4 days of treatment, as prompt treatment is important to prevent complications like rheumatic fever, kidney inflammation, or abscess formation 1

From the FDA Drug Label

In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum): otherwise the sequelae of streptococcal disease may occur. Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy

Treatment of Strep Pharyngitis in Adults

• The recommended treatment for strep pharyngitis is penicillin for a minimum of 10 days to eliminate the organism and prevent sequelae of streptococcal disease 2.
• Azithromycin can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy, such as penicillin 3.
• It is essential to note that penicillin is the usual drug of choice for the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever 3.

From the Research

Diagnosis of Strep Pharyngitis in Adults

• Common signs and symptoms of streptococcal pharyngitis include sore throat, temperature greater than 100.4 degrees F (38 degrees C), tonsillar exudates, and cervical adenopathy 4
• Available diagnostic tests include throat culture and rapid antigen detection testing, with throat culture considered the diagnostic standard 4
• 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 4

Treatment of Strep Pharyngitis in Adults

• Penicillin (10 days of oral therapy or one injection of intramuscular benzathine penicillin) is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness 4
• Amoxicillin is equally effective and more palatable 4
• Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy 4
• Guidelines recommend using clinical decision rules to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear, before prescribing antibiotics 5

Comparison of Antibiotic Treatments

• Cephalosporins versus penicillin: uncertain if there is a difference in symptom resolution, but cephalosporins may have lower clinical relapse rates 6
• Macrolides versus penicillin: uncertain if there is a difference in symptom resolution or clinical relapse rates 6
• Azithromycin versus amoxicillin: uncertain if there is a difference in symptom resolution, but azithromycin may have higher adverse event rates 6
• Carbacephem versus penicillin: low-certainty evidence suggests carbacephem may provide better symptom resolution post-treatment in adults and children 6

Controversies and Uncertainties

• Significant controversy exists regarding the best methods to diagnose GABHS and under what conditions antibiotics should be prescribed 7
• Most physicians do not follow any published guidelines for diagnosing GABHS 7
• There is no clearly superior management strategy for strep throat, and significant uncertainty remains regarding the optimal diagnostic and treatment approaches 7