From the Guidelines
Strep pharyngitis is best treated with a 10-day course of oral penicillin V (250-500 mg twice daily for adults, or 250 mg 2-3 times daily for children), as recommended by the American Heart Association 1.
Treatment Options
- For penicillin-allergic patients, alternatives include clindamycin (300 mg three times daily for 10 days), azithromycin (500 mg on day 1, then 250 mg daily for 4 more days), or a first-generation cephalosporin if the allergy is not severe, as suggested by the Infectious Diseases Society of America 1.
- Amoxicillin (500 mg twice daily for adults, or 50 mg/kg/day divided into 2-3 doses for children) is also an effective treatment option, with efficacy comparable to penicillin V 1.
Importance of Completing Antibiotic Course
Completing the full antibiotic course is crucial, even if symptoms improve, to prevent complications like rheumatic fever, which can lead to serious morbidity and mortality 1.
Supportive Care
Supportive care includes:
- Acetaminophen or ibuprofen for pain and fever
- Warm salt water gargles
- Adequate hydration Patients should rest and can return to school or work 24 hours after starting antibiotics when they're no longer contagious.
Prevention of Rheumatic Fever
Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A -hemolytic streptococcal (GAS) tonsillopharyngitis, with penicillin being the treatment of choice due to its cost-effectiveness, narrow spectrum of activity, and long-standing proven efficacy 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.
Strep Pharyngitis Treatment:
- The recommended treatment for strep pharyngitis with penicillin (PO) is a ten-day minimum course to eliminate the organism and prevent sequelae of streptococcal disease 2.
- Azithromycin (PO) can be used as an alternative to first-line therapy in individuals who cannot use first-line therapy for pharyngitis/tonsillitis caused by Streptococcus pyogenes 3.
From the Research
Diagnosis of Strep Pharyngitis
- The diagnosis of strep pharyngitis can be made using throat culture and rapid antigen detection testing, with throat culture being 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, 5.
- Clinical decision rules, such as the modified Centor or FeverPAIN score, can assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear 6, 5.
Treatment of Strep Pharyngitis
- Penicillin and amoxicillin are first-line antibiotics for the treatment of strep pharyngitis, with a recommended course of 10 days 4, 6, 5.
- First-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 4, 6, 5.
- Erythromycin and other macrolide antibiotics can be used as alternative treatments, but resistance rates may be high in some areas 7, 5.
- Corticosteroids are not recommended for symptomatic treatment of strep pharyngitis, as they provide only a small reduction in the duration of symptoms 6, 5.
Prevention and Complications
- Tonsillectomy is rarely recommended as a preventive measure for strep pharyngitis, and is typically considered only for patients with recurrent infections 4, 6.
- Chronic carriers of group A beta-hemolytic streptococci are at low risk of transmitting disease or developing invasive infections, and do not typically require treatment 4.