What are the symptoms and treatment options for Streptococcal (Strep) pharyngitis?

From the Guidelines

Strep throat is a bacterial infection caused by group A Streptococcus bacteria that requires antibiotic treatment, and the standard treatment is penicillin, typically amoxicillin 500mg three times daily for 10 days for adults, or 40-50mg/kg/day divided into three doses for children, as recommended by the Infectious Diseases Society of America 1. If you suspect strep throat, see a healthcare provider for proper diagnosis through a rapid strep test or throat culture. For penicillin-allergic patients, alternatives include azithromycin 500mg on day one followed by 250mg daily for four more days, or clindamycin 300mg three times daily for 10 days. Complete the full antibiotic course even if symptoms improve to prevent complications like rheumatic fever or kidney inflammation. While recovering, take acetaminophen or ibuprofen for pain relief, gargle with warm salt water, drink plenty of fluids, rest your voice, and use throat lozenges. Strep throat is highly contagious, so wash hands frequently, avoid sharing utensils, and replace your toothbrush after starting antibiotics. Most people can return to work or school 24 hours after starting antibiotics when they're no longer contagious, as suggested by the American College of Physicians and the Centers for Disease Control and Prevention 1. Some key points to consider include:

• The importance of proper diagnosis through a rapid strep test or throat culture to confirm the presence of group A Streptococcus bacteria 1.
• The use of penicillin as the first-line treatment for strep throat, with alternatives available for penicillin-allergic patients 1.
• The need to complete the full antibiotic course to prevent complications and ensure effective treatment 1.
• The use of analgesic therapy, such as acetaminophen or ibuprofen, to help manage pain and discomfort during recovery 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. NOTE: Penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever.

Strep throat treatment should be with penicillin as the first-line therapy, with a minimum of 10 days of treatment to eliminate the organism and prevent sequelae of streptococcal disease 2. Azithromycin can be used as an alternative in individuals who cannot use first-line therapy 3 3. Key points to consider:

• Penicillin is the usual drug of choice for strep throat
• Azithromycin can be used as an alternative
• Treatment should be for a minimum of 10 days to prevent sequelae of streptococcal disease

From the Research

Symptoms of Strep Throat

• 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
• Cough, coryza, and diarrhea are more common with viral pharyngitis 4
• Fever, tonsillar exudate, cervical lymphadenitis, and patient ages of 3 to 15 years increase clinical suspicion of group A beta-hemolytic streptococcal pharyngitis 5

Diagnosis of Strep Throat

• Available diagnostic tests include throat culture and rapid antigen detection testing 4
• Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly 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
• Clinical scoring systems, rapid antigen detection tests, throat culture, nucleic acid amplification tests, and machine learning and artificial intelligence can be used to diagnose strep throat 6

Treatment of Strep Throat

• 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, 7
• Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy 4
• There is significant resistance to azithromycin and clarithromycin in some parts of the United States 5
• Steroids are not recommended for symptomatic treatment 5

Antibiotic Resistance and Treatment Outcomes

• Increased group A beta-hemolytic streptococcus (GABHS) treatment failure with penicillin has been reported 4
• There is insufficient evidence to show clinically meaningful differences between antibiotics for group A beta hemolytic streptococci tonsillopharyngitis 8
• Penicillin or amoxicillin is recommended as first choice, given the absence of resistance and low cost 8