Treatment of Strep Pharyngitis in Children

Recommended Antibiotic Regimens

The American Academy of Pediatrics and the Infectious Diseases Society of America recommend intramuscular benzathine penicillin G 600,000 units as a single dose for children weighing less than 27 kg with confirmed strep pharyngitis, particularly when oral medication compliance is uncertain 1
Children weighing 27 kg or more should receive 1,200,000 units of benzathine penicillin G as a single intramuscular injection 1
The intramuscular route is specifically indicated when compliance with a 10-day oral regimen is questionable or cannot be assured, according to the Infectious Diseases Society of America 2, 1
The patient has previously failed oral antibiotic therapy due to non-compliance, and the intramuscular route may be considered 2

The Infectious Diseases Society of America guidelines state that this regimen has "strong, high-quality" evidence supporting its efficacy 1
The primary objectives of antibiotic treatment are preventing acute rheumatic fever, preventing suppurative complications, hastening symptom resolution, limiting disease spread, and permitting earlier return to school or daycare, as recommended by the Infectious Diseases Society of America 1

If the family can reliably administer oral medication for 10 full days, amoxicillin 50 mg/kg once daily (maximum 1,000 mg) for 10 days is the preferred oral option, according to the Infectious Diseases Society of America 1
Amoxicillin is often chosen over penicillin V in young children due to better palatability of the suspension, as recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America 2

The Infectious Diseases Society of America recommends not using the IM shot as first-line in all cases, but rather reserving it for cases where compliance is uncertain 1
The American Academy of Pediatrics and the Infectious Diseases Society of America recommend ensuring the correct weight-based dose (600,000 units for <27 kg) and not underdosing 1
The Infectious Diseases Society of America recommends not skipping diagnostic confirmation and always confirming strep pharyngitis with rapid antigen detection test or throat culture before treating 1

The American Academy of Pediatrics recommends offering acetaminophen or ibuprofen for moderate to severe symptoms or high fever, and avoiding aspirin in children due to Reye syndrome risk 1
The Infectious Diseases Society of America recommends against using corticosteroids for symptomatic treatment 1

The American Academy of Pediatrics recommends treating streptococcal pharyngitis in children with oral amoxicillin 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for a full 10 days, due to its narrow spectrum, proven efficacy, safety profile, and low cost 3, 4.
No penicillin-resistant Group A streptococcal (GAS) strains have ever been documented anywhere in the world, making penicillin-based antibiotics the gold standard for treatment 3, 4.

The Infectious Diseases Society of America recommends a full 10-day course of antibiotics to maximize pharyngeal eradication of GAS, prevent acute rheumatic fever, and prevent suppurative complications 3, 4, 5.
Shortening the course by even a few days dramatically increases treatment failure rates and the risk of acute rheumatic fever 6, 5.

For patients with non-anaphylactic penicillin allergies, first-generation cephalosporins such as cephalexin are preferred, with a dosing regimen of 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 3, 6, 7.
For patients with anaphylactic penicillin allergies, clindamycin is a suitable alternative, with a dosing regimen of 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 3, 6, 7.

The Centers for Disease Control and Prevention recommend performing a rapid antigen detection test (RADT) first, followed by a throat culture if the RADT is negative, to confirm the diagnosis of streptococcal pharyngitis 3, 7, 5.

The American Academy of Pediatrics recommends using acetaminophen or NSAIDs (such as ibuprofen) for moderate to severe symptoms or high fever, and advises against using aspirin in children due to the risk of Reye syndrome 3, 6, 7.

The Infectious Diseases Society of America advises against prescribing broad-spectrum cephalosporins when narrow-spectrum agents are appropriate, as they are more expensive and promote antibiotic resistance 4, 6.
The American Academy of Pediatrics recommends against using trimethoprim-sulfamethoxazole (Bactrim) for strep throat, as it has a 50% resistance rate and is not effective against GAS 6.