From the Guidelines
Strep pharyngitis is typically treated with a 10-day course of oral penicillin, specifically penicillin V potassium 250 mg twice daily for children or 500 mg twice daily for adults, as recommended by the Infectious Diseases Society of America 1.
Treatment Options
For patients with penicillin allergy, alternatives include:
- Amoxicillin (50 mg/kg once daily, maximum 1000 mg, for 10 days)
- Cephalexin (20 mg/kg twice daily, maximum 500 mg per dose, for 10 days)
- Azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days) in cases of severe penicillin allergy, as supported by the guideline 1.
Diagnosis and Treatment
Treatment should begin promptly after diagnosis, which is typically made using rapid strep testing or throat culture 1. Antibiotics help reduce symptom duration, prevent complications like rheumatic fever and peritonsillar abscess, and decrease transmission to others 1. Patients should complete the full antibiotic course even if symptoms improve before completion.
Symptomatic Relief
Symptomatic relief can be achieved with:
- Acetaminophen or ibuprofen for pain and fever
- Warm salt water gargles
- Adequate hydration Most patients can expect symptom improvement within 24-48 hours of starting antibiotics, and they are generally no longer contagious after 24 hours of antibiotic therapy 1.
Key Considerations
The choice of antibiotic should be based on the patient's allergy history and the severity of the infection, with penicillin being the first-line treatment due to its efficacy, safety, and low cost 1. It is essential to complete the full course of antibiotics to ensure the infection is fully cleared and to reduce the risk of complications 1. The guideline from the Infectious Diseases Society of America 1 provides the most recent and comprehensive recommendations for the diagnosis and treatment of strep pharyngitis.
From the FDA Drug Label
Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14 Day 30 Bacteriologic Eradication: Azithromycin 323/340 (95%) 255/330 (77%) Penicillin V 242/332 (73%) 206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin 336/343 (98%) 310/330 (94%) Penicillin V 284/338 (84%) 241/325 (74%)
Azithromycin is effective in the treatment of strep pharyngitis. The clinical success rate for azithromycin was 98% at Day 14 and 94% at Day 30, compared to 84% and 74% for penicillin V, respectively. Bacteriologic eradication rates were also higher for azithromycin, at 95% at Day 14 and 77% at Day 30, compared to 73% and 63% for penicillin V. 2
From the Research
Strep Pharyngitis Treatment Options
- The primary treatment for strep pharyngitis is antibiotics, with the goal of preventing acute rheumatic fever and suppurative complications, hastening resolution of clinical signs and symptoms, and preventing transmission to close contacts 3.
- Penicillins, such as penicillin V, are the recommended first-line therapy for strep pharyngitis, with a 10-day course usually given 2 or 3 times per day 3.
- Cephalosporins are an alternative to penicillins and may provide higher bacteriologic eradication rates, with some cephalosporins approved for a 5-day dosing schedule 4, 3.
- Macrolides, such as erythromycin, are also an option, but increased resistance and failure rates have been reported 4.
- Azithromycin has been studied as a potential treatment for strep pharyngitis, with some studies showing similar clinical efficacy to penicillin V, but lower bacteriologic eradication rates 5, 6, 7.
Comparison of Treatment Options
- A study comparing azithromycin to penicillin V found that azithromycin was as clinically effective and safe as penicillin, but appeared inferior in eliminating GABHS from the throat 5.
- Another study found that azithromycin had similar high levels of clinical efficacy, but lower levels of bacteriologic eradication, compared to penicillin V 6.
- A study comparing 3-day azithromycin to 10-day penicillin V treatment found that azithromycin was not an effective alternative to penicillin for the treatment of GABHS pharyngitis, even for those children with azithromycin-susceptible strains 7.
Considerations for Treatment
- The choice of treatment should consider factors such as patient compliance, palatability, and potential drug-related adverse events 3.
- Cephalosporins may be a useful alternative for patients with penicillin allergy or for the treatment of recurrent strep pharyngitis 4.
- Azithromycin may be considered for patients who are unable to tolerate penicillin or cephalosporins, but its use should be weighed against the potential for lower bacteriologic eradication rates 5, 6, 7.