Treatment of Streptococcal Pharyngitis

First-Line Treatment for Non-Allergic Patients

The American Academy of Pediatrics and the Infectious Diseases Society of America recommend penicillin or amoxicillin as the first-line treatment for strep pharyngitis in non-allergic patients, given for 10 days to eradicate the organism and prevent rheumatic fever 1
Penicillin V is the drug of choice at 250 mg four times daily OR 500 mg twice daily for 10 days in adults 1
Amoxicillin is equally effective and offers simpler dosing: 50 mg/kg once daily (maximum 1000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
Benzathine penicillin G intramuscularly provides single-dose treatment: 600,000 units for patients <27 kg; 1,200,000 units for patients ≥27 kg 1

First-generation cephalosporins are the preferred alternatives for patients without immediate hypersensitivity reactions, with a cross-reactivity risk of only 0.1% in patients with non-severe, delayed penicillin reactions 1, 2
Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 1, 2
Cefadroxil: 30 mg/kg once daily (maximum 1 gram) for 10 days 1
Clindamycin is the preferred alternative for patients with immediate hypersensitivity reactions, with dosing at 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1, 2
Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days, with a low resistance rate among Group A Streptococcus 1, 2

A full 10-day course is essential for all antibiotics EXCEPT azithromycin to achieve maximal pharyngeal eradication and prevent acute rheumatic fever 1, 2

Macrolide resistance among Group A Streptococcus is approximately 5-8% in the United States but varies geographically and temporally 1, 2
Clindamycin resistance remains very low at approximately 1% in the United States 2

Acetaminophen or NSAIDs (such as ibuprofen) should be considered for moderate to severe symptoms or high fever 1
Aspirin must be avoided in children due to risk of Reye syndrome 1, 2
Corticosteroids are NOT recommended as adjunctive therapy 1, 2

Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions - the 10% cross-reactivity risk makes this dangerous 1, 2
Do not shorten treatment courses below 10 days (except azithromycin's 5-day regimen) - this increases treatment failure and rheumatic fever risk 1, 2

Therapy can be safely postponed up to 9 days after symptom onset and still prevent acute rheumatic fever 2
Routine post-treatment throat cultures or rapid antigen tests are NOT recommended for asymptomatic patients who have completed therapy 1, 2
Chronic carriers generally do not require treatment as they are unlikely to spread infection or develop complications 1, 2
Asymptomatic household contacts should NOT be tested or treated routinely 1