Best Antibiotic for Strep Throat

First-Line Treatment Recommendations

The American Academy of Pediatrics recommends penicillin V as the drug of choice for adults and older children, with a dosage of 250 mg three to four times daily or 500 mg twice daily for 10 days 3
For younger children, amoxicillin is preferred, with a dosage of 50 mg/kg once daily (maximum 1000 mg) for 10 days, due to better taste acceptance and availability as suspension 1, 2, 3
Intramuscular benzathine penicillin G is an alternative, with a dosage of 1.2 million units as a single injection, preferred when compliance with 10-day oral therapy is unlikely 3, 4

For non-immediate penicillin allergy, first-generation cephalosporins such as cephalexin are recommended, with a dosage of 20 mg/kg per dose twice daily for 10 days, and strong, high-quality evidence for efficacy 5
For immediate/anaphylactic penicillin allergy, clindamycin is the preferred alternative, with a dosage of 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days, and strong, moderate-quality evidence 5, 4

Most antibiotics require a full 10-day course to achieve maximal pharyngeal eradication, with the exception of azithromycin which requires only 5 days due to prolonged tissue half-life 5, 4
Antibiotics should not be used in patients with 0-2 Centor criteria, and for patients with 3-4 Centor criteria, the benefits and risks of treatment should be discussed 1, 2
Common pitfalls to avoid include using azithromycin or other macrolides as first-line when penicillin can be used, assuming all penicillin-allergic patients cannot receive cephalosporins, and prescribing amoxicillin to adolescents without considering Epstein-Barr virus risk 4, 5, 1, 2