From the Guidelines
Strep pharyngitis is typically treated with a 10-day course of oral penicillin V (phenoxymethylpenicillin) at a dose of 250-500 mg twice daily for adults or 250 mg 2-3 times daily for children, as recommended by the Infectious Diseases Society of America 1. The treatment of strep pharyngitis aims to eliminate the causative bacteria, Group A Streptococcus, and prevent complications such as rheumatic fever and glomerulonephritis.
- The recommended antibiotic regimens for strep pharyngitis include:
- Penicillin V: 250-500 mg twice daily for adults or 250 mg 2-3 times daily for children
- Amoxicillin: 500 mg twice daily for adults or 50 mg/kg/day divided into two doses for children
- For penicillin-allergic patients, alternative antibiotics such as:
- First-generation cephalosporins like cephalexin (if not severely allergic)
- Macrolides such as azithromycin (500 mg on day 1, then 250 mg daily for 4 more days)
- A single intramuscular injection of benzathine penicillin G can be considered for patients with compliance concerns. Symptomatic relief can be achieved with:
- Acetaminophen or ibuprofen for pain and fever
- Salt water gargles for throat discomfort Patients should rest, stay hydrated, and can return to school or work 24 hours after starting antibiotics as they're no longer contagious at that point. The Infectious Diseases Society of America recommends completing the full antibiotic course, even if symptoms improve, to prevent complications like rheumatic fever and glomerulonephritis 1.
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 treatment of streptococcal pharyngitis typically involves the use of antibiotics to prevent acute rheumatic fever and suppurative complications, hasten resolution of clinical signs and symptoms, and prevent transmission to close contacts 3.
- Penicillin V is the recommended first-line therapy for streptococcal pharyngitis, usually given for 10 days, 2 or 3 times per day 3, 4.
- Alternative treatments to penicillin V include other penicillins, macrolides, and cephalosporins, with cephalosporins providing somewhat higher bacteriologic eradication rates than penicillin V 3, 5.
Azithromycin vs. Penicillin V
- Studies have compared the efficacy of azithromycin and penicillin V in the treatment of acute group A streptococcal pharyngitis, with results showing that azithromycin is as clinically effective as penicillin V, but appears to be inferior in eliminating group A beta-hemolytic streptococci (GABHS) from the throat 6, 7.
- Azithromycin has been shown to have a lower bacteriologic eradication rate compared to penicillin V, with one study reporting a bacteriologic eradication rate of 65% for azithromycin compared to 82% for penicillin V 6.
- Another study found that treatment with 3-day, once daily 10 mg/kg azithromycin for GABHS pharyngitis was associated with similar high levels of clinical efficacy, but lower levels of bacteriologic eradication, than with 10-day 100,000 IU/kg/day penicillin V 7.
Cephalosporins as an Alternative
- Cephalosporins have been suggested as an alternative to penicillin V, particularly for children with streptococcal pharyngitis, due to their higher bacteriologic eradication rates and effectiveness against chronic GABHS carriage 3, 5.
- Some cephalosporins, such as cefdinir and cefpodoxime proxetil, can be administered twice daily and have a more convenient 5-day dosing schedule, which may increase adherence to the full course of therapy 3.