Antibiotic Treatment for Strep Throat in Patients with Penicillin Allergy

Treatment Recommendations

For patients with penicillin allergy who have strep throat, the Infectious Diseases Society of America recommends a 10-day course of a first-generation cephalosporin (if no history of immediate hypersensitivity) or clindamycin (if anaphylactic penicillin allergy) as first-line treatment 1, 2, 3
The American Academy of Pediatrics recommends first-generation cephalosporins as the preferred treatment option for non-anaphylactic penicillin allergy, with options including cephalexin and cefadroxil 2, 4
For immediate/anaphylactic penicillin allergy, clindamycin is recommended at a dose of 7 mg/kg/dose three times daily (maximum 300 mg/dose) for 10 days 2, 5

First-generation cephalosporins have strong, high-quality evidence for efficacy in non-anaphylactic penicillin-allergic patients, according to the Infectious Diseases Society of America 3, 4
Clindamycin has strong, moderate-quality evidence with approximately 1% resistance among Group A Streptococcus isolates in the United States, as reported by the Centers for Disease Control and Prevention 2, 5

Up to 10% of patients with immediate hypersensitivity to penicillin may have cross-reactivity with cephalosporins, so these should be avoided in patients with anaphylactic-type reactions to penicillin, as advised by the American Academy of Allergy, Asthma, and Immunology 2, 5
Most antibiotics require a full 10-day course to achieve maximal pharyngeal eradication of Group A Streptococcus, with azithromycin being the exception (5-day course), according to the Infectious Diseases Society of America 1, 6

Acetaminophen or NSAIDs can be used for moderate to severe symptoms or high fever, as recommended by the American Academy of Pediatrics 2, 6
Aspirin should be avoided in children due to the risk of Reye syndrome, as advised by the Centers for Disease Control and Prevention 2, 4