Treatment of Streptococcal Pharyngitis

Initial Treatment and Alternatives

• The American Academy of Pediatrics recommends amoxicillin oral as the first-line treatment for streptococcal pharyngitis in children, with a dosage of 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
• Penicillin V oral is an alternative treatment option, with a dosage of 250 mg two or three times daily for 10 days, and has a narrow spectrum, low cost, and no developed resistance in five decades 1, 2
• Cefalexina can be used as an alternative treatment option if there is no history of anaphylactic hypersensitivity, with a dosage of 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
• The following table summarizes the recommended antibiotic dosages:

3, 4, 5, 6, 7

• Treatment failure is defined as persistent symptoms after 72 hours of appropriate antibiotic therapy, according to the American Academy of Otolaryngology-Head and Neck Surgery 8
• The American Heart Association recommends alternative treatments, including narrow-spectrum cephalosporins, clindamycin, or amoxicillin-clavulanic acid, for patients who fail initial antibiotic treatment for streptococcal pharyngitis, with the specific choice depending on the patient's initial treatment and allergy status 4

Post-Treatment Evaluation

• Post-treatment throat cultures are only indicated in patients who remain symptomatic, have recurrent symptoms, or have a history of rheumatic fever, as recommended by the American Heart Association 4
• Routine post-treatment throat cultures are not recommended 1

First-Line Alternatives

• High-dose amoxicillin-clavulanate (adults: 2000 mg amoxicillin/125 mg clavulanate twice daily; children: 90 mg/kg/day amoxicillin with 6.4 mg/kg/day clavulanate) is a recommended first-line alternative, according to the American Academy of Allergy, Asthma, and Immunology 9
• Narrow-spectrum cephalosporins (cefpodoxime, cefuroxime axetil, or cefdinir) are recommended as first-line alternatives by the American Heart Association 4
• Clindamycin (adults: 300-450 mg three times daily; children: 7 mg/kg three times daily, maximum 300 mg per dose) for 10 days is a recommended first-line alternative, according to the American Heart Association 4

Penicillin-Allergic Patients

• Clindamycin is recommended as an alternative for penicillin-allergic patients, according to the American Academy of Otolaryngology-Head and Neck Surgery 8
• Combination therapy with clindamycin and a third-generation oral cephalosporin (cefixime or cefpodoxime) is recommended for non-type I hypersensitivity, according to the American Academy of Otolaryngology-Head and Neck Surgery 8
• Respiratory fluoroquinolones (levofloxacin or moxifloxacin) are recommended in adults only, according to the American Academy of Otolaryngology-Head and Neck Surgery 8

Carrier State

• Carriers of group A streptococci generally do not need identification or treatment, according to the American Heart Association 4
• Carriers are not considered important in spreading group A streptococci to others, according to the American Heart Association 4
• Exception: carriers who have a history of rheumatic fever or family members with rheumatic fever should be treated, according to the American Heart Association 4

Evaluation and Consultation

• Underlying conditions (allergies, immunodeficiency, anatomical abnormalities) should be evaluated, according to the American Academy of Allergy, Asthma, and Immunology 9
• Consultation with an allergist-immunologist or otolaryngologist should be considered for persistent cases, according to the American Academy of Allergy, Asthma, and Immunology 9

Avoiding Unnecessary Treatments

• Asymptomatic patients who continue to harbor group A streptococci after appropriate therapy should not be automatically retreated, according to the American Heart Association 4
• Older fluoroquinolones like ciprofloxacin should not be used due to limited activity against group A streptococci, according to the American Heart Association 4
• Non-infectious causes of persistent symptoms (allergic rhinitis, migraines, etc.) should be considered, according to the American Academy of Otolaryngology-Head and Neck Surgery 8

Symptom Management

• The use of analgesics/antipyretics such as acetaminophen is recommended for moderate to severe symptoms or high fever control 1
• Aspirin should be avoided in children due to the risk of Reye's syndrome 1
• The use of corticosteroids as adjuvant therapy is not recommended 1

Preventing Complications

• Completing the full 10-day course of antibiotic treatment is essential to prevent acute rheumatic fever, even if symptoms improve before 1, 7
• Aggressive infections require prompt and effective treatment to prevent complications and improve patient outcomes, as stated by the Infectious Diseases Society of America 10
• Surgical consultation is recommended for aggressive infections with signs of systemic toxicity, as stated by the Infectious Diseases Society of America 10
• For patients with severe infection or immunocompromise, consideration of broader coverage with Vancomycin plus piperacillin-tazobactam or a carbapenem is advised, according to the Infectious Diseases Society of America 10

Diagnosis and Testing

• Antibiotics should only be prescribed for sore throat when a patient has 3-4 Centor criteria, suggesting a high likelihood of streptococcal infection, and the modest benefits of antibiotics, including 1-2 days symptom reduction, must be weighed against side effects, impact on microbiota, increased resistance, and costs 2
• For patients with 0-2 Centor criteria, no antibiotics or testing are needed, while those with 3-4 Centor criteria should undergo Rapid Antigen Detection Test (RADT) 2
• Penicillin V or amoxicillin are recommended as first-line treatments for positive RADT results, with cephalexin or macrolides considered as second-line options for patients with penicillin allergy 2

Prevention and Control

• Hand hygiene, avoiding close contact with infected individuals, and not sharing utensils or drinks are important measures to prevent the spread of infection, as recommended by the Centers for Disease Control and Prevention and the Infectious Diseases Society of America 4, 7, 5, 11, 12
• Healthcare workers with symptomatic GAS infection should be excluded from work until 24 hours of appropriate treatment and resolution of symptoms, as recommended by the American College of Physicians 12
• Isolation precautions should be maintained for a minimum of 24 hours of effective antibiotic therapy, as recommended by the Journal of Infection guidelines 12

Complications and Special Considerations

• Suppurative complications of Strep A pharyngitis, such as quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, and acute sinusitis, are rare, according to the European Society of Clinical Microbiology and Infectious Diseases 2
• Non-suppurative complications, including acute rheumatic fever and acute glomerulonephritis, are also rare, as noted by the European Society of Clinical Microbiology and Infectious Diseases 2
• The American Academy of Otolaryngology-Head and Neck Surgery recommends watchful waiting for patients with recurrent throat infections if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years, with tonsillectomy reserved for those meeting specific frequency criteria with documented symptoms (Strong recommendation) 13
• Dosage adjustment is necessary in patients with impaired renal function, according to the Centers for Disease Control and Prevention 14
• No dosage adjustment is needed in patients with impaired hepatic function and normal renal function, as stated by the Centers for Disease Control and Prevention 14

Antibiotic Course and De-escalation

• The Society of Critical Care Medicine and the European Society of Intensive Care Medicine recommend a total antibiotic course of 7-10 days, with IV therapy until clinically improved, then transition to oral therapy to complete the course 15, 16
• Longer courses may be needed for patients with slow clinical response, complications, or immunocompromised status, as recommended by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine 15, 16
• De-escalating therapy once culture results are available and clinical improvement is noted, and transitioning to oral therapy when clinically stable, as suggested by the European Society of Intensive Care Medicine 16