Treatment of Streptococcal Pharyngitis

Introduction to Appropriate Treatment

The Infectious Diseases Society of America explicitly states that sulfonamides are not recommended for treatment of group A streptococcal pharyngitis because of higher rates of resistance among group A streptococci and the frequent failure of these agents to eradicate even susceptible organisms from the pharynx 1, 2, 3
The American Academy of Otolaryngology-Head and Neck Surgery confirms that trimethoprim-sulfamethoxazole should not be used for strep throat due to high resistance rates and is not recommended for Group A Streptococcus 7

Penicillin V remains the treatment of choice for strep throat due to proven efficacy, safety, narrow spectrum, and low cost, with dosing for adults at 250 mg three to four times daily or 500 mg twice daily for 10 days, and for children at 250 mg two to three times daily for 10 days 1, 4, 5
Amoxicillin is often substituted for penicillin V in children due to better taste acceptance, with equal efficacy at 50 mg/kg once daily (maximum 1000 mg) for 10 days, although this fact is from a less preferred source, it is still notable 6

First-generation cephalosporins, such as cephalexin 20 mg/kg twice daily for 10 days, are preferred for non-immediate hypersensitivity reactions, according to less preferred sources 6, 7
Clindamycin is the best choice for immediate/anaphylactic penicillin allergy at 7 mg/kg three times daily for 10 days, as per less preferred sources 6, 7
Azithromycin is an alternative macrolide option at 12 mg/kg once daily for 5 days, though macrolide resistance is approximately 5-8% in the United States 4, 7

The primary goal of treating strep throat is preventing serious complications, particularly acute rheumatic fever, which can cause permanent heart damage, and only intramuscular repository penicillin has been proven in controlled studies to prevent rheumatic fever 1, 8
Using Bactrim risks treatment failure, persistent infection, continued transmission, and potentially life-threatening complications like rheumatic fever and post-streptococcal glomerulonephritis 1