Treatment for Recurrent Streptococcal Pharyngitis in Patients with Amoxicillin Allergy

First-Line Treatment Options for Penicillin-Allergic Patients

The American Academy of Family Physicians recommends first-generation cephalosporins, such as cephalexin (20 mg/kg per dose twice daily, maximum 500 mg per dose) or cefadroxil (30 mg/kg once daily, maximum 1 g), for 10 days in patients without anaphylactic sensitivity to penicillin 1, 2
The Infectious Diseases Society of America recommends clindamycin (7 mg/kg per dose three times daily, maximum 300 mg per dose) for 10 days in patients with anaphylactic sensitivity to penicillin 1, 2
The American Academy of Pediatrics recommends clarithromycin (7.5 mg/kg per dose twice daily, maximum 250 mg per dose) for 10 days in patients with anaphylactic sensitivity to penicillin 3, 2
Azithromycin (12 mg/kg once daily, maximum 500 mg) for 5 days is also recommended for patients with anaphylactic sensitivity to penicillin 3

The Centers for Disease Control and Prevention recommends confirming each episode with rapid antigen detection test (RADT) or throat culture 1, 4
A positive RADT is diagnostic and does not require backup culture 4

The American College of Physicians recommends considering whether the patient is experiencing true recurrent infections or is a chronic carrier with viral infections 3, 5
Resistance to macrolides (azithromycin and clarithromycin) varies geographically and should be considered when selecting treatment 2

The American Academy of Family Physicians recommends using acetaminophen or NSAIDs for moderate to severe symptoms or high fever 3
Aspirin should be avoided in children due to the risk of Reye syndrome 3, 5
Corticosteroids are not recommended for routine use 3, 4

Overdiagnosis and overtreatment of viral pharyngitis as bacterial infection should be avoided 4
Failing to distinguish between true recurrent infections and chronic carriage with viral infections should be avoided 3, 5
Using macrolides in areas with high resistance rates should be avoided 2
Unnecessary tonsillectomy solely to reduce frequency of GAS pharyngitis should be avoided 2, 5

The American Academy of Otolaryngology-Head and Neck Surgery recommends watchful waiting for children with recurrent streptococcal pharyngitis who have had <7 episodes in the past year, <5 episodes per year over 2 years, or <3 episodes per year over 3 years 6, 7, 8, 9
Every suspected episode of streptococcal pharyngitis must be confirmed with a rapid antigen detection test (RADT) or throat culture before treating with antibiotics, as recommended by the American Academy of Family Physicians 10
For children with confirmed streptococcal pharyngitis, documentation of each episode should include sore throat symptoms, and at least one of the following: temperature ≥38.3°C (101°F), cervical lymphadenopathy, tonsillar exudate, or positive RADT or throat culture 6, 10

Tonsillectomy may be considered for children who meet specific frequency criteria, including ≥7 episodes in 1 year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 6, 7, 8
The American Academy of Otolaryngology-Head and Neck Surgery also recommends considering tonsillectomy for children with modifying factors, such as multiple antibiotic allergies or intolerances, PFAPA syndrome, history of >1 peritonsillar abscess, or significant impact on quality of life 6, 7, 8

The American Academy of Otolaryngology-Head and Neck Surgery recommends active surveillance, including collating documentation from all providers, recording clinical characteristics of each episode, documenting RADT or culture results, tracking school absences and quality of life impacts, and reassessing annually whether frequency criteria are being approached 6, 7, 9