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Treatment of pharyngitis due to group A Streptococcus in adults

Treatment of pharyngitis due to group A Streptococcus in adults

Antibiotic class	Drug	Dosing in adults*	Advantages	Disadvantages
Penicillins (preferred)	Penicillin V	500 mg orally two to three times daily for 10 days	Narrow spectrum No documented resistance Low cost	Three-times-daily dosing; however, twice-daily regimen appears to be as effective as thrice daily^[1]
	Amoxicillin*	500 mg orally twice daily for 10 days 1000 mg (immediate release) once daily for 10 days	Also available as once-daily extended-release tablet^¶
	Penicillin G benzathine* (Bicillin L-A)	1.2 million units IM as a single dose	Can be given as a single dose Ensured adherence Only drug studied for prevention of acute rheumatic fever	Variable availability High cost Injection site pain
Cephalosporins (potential alternatives for mild reactions to penicillin^Δ)	Cephalexin* (first generation)	500 mg orally twice daily for 10 days	High efficacy rate Narrower spectrum than later-generation cephalosporins	Broader spectrum than penicillin Greater potential to induce antibiotic resistance
	Cefadroxil* (first generation)	1 g orally daily for 10 days	Once daily High efficacy rate Narrower spectrum than later-generation cephalosporins	Broader spectrum than penicillin Greater potential to induce antibiotic resistance
	Cefuroxime* (second generation)	250 mg orally twice daily for 10 days	High efficacy rate Narrower spectrum than later-generation cephalosporins	Broader spectrum than penicillin and first-generation cephalosporins Greater potential to induce antibiotic resistance
	Cefpodoxime* (third generation)	100 mg orally twice daily for 5 to 10 days	High efficacy rate FDA approved for 5-day course	Broader spectrum than penicillin and earlier-generation cephalosporins Greater potential to induce antibiotic resistance
	Cefdinir* (third generation)	300 mg orally twice daily for 5 to 10 days or 600 mg orally once daily for 10 days	Once-daily option High efficacy rate FDA approved for 5-day course	Broader spectrum than penicillin and earlier-generation cephalosporins Greater potential to induce antibiotic resistance
	Cefixime (third generation)	400 mg orally once daily for 10 days	Once daily High efficacy rate	Broader spectrum than penicillin Greater potential to induce antibiotic resistance
Macrolides (alternatives for patients with anaphylaxis or other IgE-mediated reactions or severe delayed reactions to penicillin^Δ)	Azithromycin	12 mg/kg/day (maximum 500 mg/dose) 5 days^◊	Once daily	Growing rates of resistance Rarely associated with prolonged QT interval and TdP
	Clarithromycin*	250 mg orally twice daily for 10 days		Growing rates of resistance Greater gastrointestinal side effects than azithromycin Causes CYP3A4 drug interactions Rarely associated with prolonged QT interval and TdP
Lincosamides (alternative when macrolide resistance is a concern and penicillins and cephalosporins cannot be used)	Clindamycin	300 mg orally three times daily for 10 days		Growing rates of resistance High side-effect profile (ie, gastrointestinal)

IM: intramuscularly; FDA: US Food and Drug Administration: TdP: torsades de pointes.
* Dose alteration may be needed for renal insufficiency.
¶ Once-daily immediate-release amoxicillin appears to be non-inferior to penicillin V or amoxicillin administered in multiple daily doses, primarily based on studies in children and adolescents. An extended-release preparation of amoxicillin is also available. The dose in adults is 775 mg orally once daily for 10 days.
Δ Approach to patients with penicillin allergy varies among experts and allergy severity; refer to the UpToDate text for additional detail.
◊ A 3-day course is approved and widely prescribed in Europe and other regions.

Reference:

Lan AJ, Colford JM, Colford JM Jr. The impact of dosing frequency on the efficacy of 10-day penicillin or amoxicillin therapy for streptococcal tonsillopharyngitis: A meta-analysis. Pediatrics 2000; 105:E19.

Data from:

Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of Group A Streptococcal pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55:e86.
Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: A scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Academy of Pediatrics. Circulation 2009; 119:1541.

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