Short-course antimicrobial therapy of streptococcal pharyngitis

While penicillin administered orally or intramuscularly is the least expensive course of pharyngitis treatment, there are many limitations to its use. These include the need for extended treatment (i.e., 10 days) and poor palatability of its liquid formulation and an alarming increase in the rates of failure with standard doses of either IM or oral penicillin. Increasing rates of beta-lactamase-producing normal flora and eradication of protective alpha-streptococci may also play a role in penicillin treatment failure. Thus practitioners may consider switching to amoxicillin in higher doses (up to 40 to 60 mg/kg/day divided twice daily, maximum dose 1 gram twice daily) as first-line therapy (Figure 1), similar to what we have done for acute otitis media. Five-day short-course treatment with cefdinir or cefpodoxime may be suitable alternatives, especially in patients with penicillin hypersensitivity (not anaphylaxis). Concerns with higher costs of these second-line agents and potential for resistance must be balanced with concerns for patient adherence with penicillin treatment and the recent increasing rate of penicillin failures. In light of recent reports regarding the high rate of failure with azithromycin and increasing macrolide resistance, clinicians should prescribe standard doses of this drug for 5 days with caution.