What are the most effective antibiotics for treating strep throat. How are proper dosages determined for different age groups. When are antibiotics necessary for strep throat treatment. What are the key symptoms that distinguish strep throat from other sore throats.

Optimal Antibiotic Choices for Strep Throat

Strep throat, caused by group A Streptococcus bacteria, requires prompt and effective treatment to prevent complications and reduce symptom duration. The Centers for Disease Control and Prevention (CDC) recommends specific antibiotics as first-line treatments:

• Penicillin
• Amoxicillin

These antibiotics are highly effective against group A strep, with the CDC noting, “There has never been a report of a clinical isolate of group A strep that is resistant to penicillin.” This makes them the gold standard for strep throat treatment.

For individuals with penicillin allergies, alternative antibiotics include:

• Narrow-spectrum cephalosporins (e.g., cephalexin, cefadroxil)
• Clindamycin
• Azithromycin
• Clarithromycin

It’s important to note that resistance to azithromycin and clarithromycin has been reported, potentially affecting their efficacy in some cases.

Antibiotic Dosages for Strep Throat Treatment

Proper dosing of antibiotics is crucial for effective treatment of strep throat. The CDC provides specific recommendations based on age, weight, and the chosen antibiotic:

For Patients Without Penicillin Allergy:

Oral Penicillin V:

• Children: 250mg twice daily or 250mg three times daily for 10 days
• Adolescents and adults: 250mg four times daily or 500mg twice daily for 10 days

Oral Amoxicillin:

• Children and adults: 50 mg/kg once daily (maximum 1000mg once daily) for 10 days
• Alternative: 25 mg/kg twice daily (maximum 500mg twice daily) for 10 days

Intramuscular Benzathine Penicillin G:

• Children <27 kg: 600,000 units as a single dose
• Children and adults ≥27 kg: 1,200,000 units as a single dose

For Patients With Penicillin Allergy:

Oral Cephalexin: 20 mg/kg twice daily (maximum 500 mg twice daily) for 10 days

Oral Cefadroxil: 30 mg/kg once daily (maximum 100mg once daily) for 10 days

Oral Clindamycin: 7 mg/kg three times daily (maximum 300 mg three times daily) for 10 days

Oral Azithromycin: 12 mg/kg once daily for the first day (maximum 500 mg), followed by 6 mg/kg once daily (maximum 250 mg once daily) for the next 4 days

Oral Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg twice daily) for 10 days

The Necessity of Antibiotics in Strep Throat Treatment

Do all cases of strep throat require antibiotic treatment? While most strep throat infections may resolve on their own, the CDC recommends antibiotic treatment for all patients with a positive rapid antigen detection test (RADT) or throat culture, regardless of age. This recommendation is based on several important factors:

1. Prevention of complications: Antibiotics reduce the risk of acute rheumatic fever and other potential complications such as oral abscesses or mastoiditis.
2. Symptom relief: Antibiotic treatment can shorten the duration of strep throat symptoms, providing faster relief to patients.
3. Reduced transmission: Treating with antibiotics decreases the likelihood of spreading the infection to family members, friends, and other close contacts.

It’s crucial to note that viral sore throats should not be treated with antibiotics, as they are ineffective against viruses and can contribute to antibiotic resistance.

Identifying Strep Throat: Key Symptoms and Diagnosis

Recognizing the symptoms of strep throat is essential for prompt diagnosis and treatment. Strep throat typically presents with:

• Sudden onset of severe sore throat
• Very red and swollen tonsils and throat
• Possible streaks of pus or red spots on the roof of the mouth
• Headache
• Fever and chills
• Swollen and tender lymph nodes in the neck

Children may also experience nausea and vomiting. Importantly, strep throat usually does not cause cough, runny nose, hoarseness, mouth ulcers, or conjunctivitis. The presence of these symptoms suggests a viral cause rather than strep throat.

How is strep throat definitively diagnosed? A throat swab cultured in a laboratory is the gold standard for diagnosis. If the culture is positive, your doctor will prescribe appropriate antibiotics to manage the infection and prevent complications.

Scarlet Fever: A Potential Complication of Strep Throat

In some cases, particularly in children aged 4 to 8 years, strep throat can lead to a condition called scarlet fever or scarlatina. This occurs when individuals are susceptible to the toxins produced by the Streptococcus pyogenes bacteria. Scarlet fever is characterized by:

• A bright red rash that feels like sandpaper to the touch
• Typically follows a strep throat infection
• Can also occur after impetigo (school sores)

Recognizing scarlet fever is important as it requires prompt antibiotic treatment to prevent potential complications.

Treatment Duration and Special Considerations

How long should strep throat be treated with antibiotics? The standard duration of antibiotic treatment for strep throat is 10 days. This extended course helps ensure complete eradication of the bacteria and reduces the risk of complications.

For children who have difficulty swallowing tablets or capsules, liquid antibiotic formulations are available. In some cases, particularly for patients who may have difficulty adhering to a 10-day oral regimen, a single intramuscular injection of penicillin may be considered as an alternative treatment option.

Preventing the Spread of Strep Throat

Strep throat is highly contagious, especially in close-contact environments like schools and households. To minimize transmission:

• Practice good hand hygiene
• Avoid sharing personal items like utensils or drinking glasses
• Cover your mouth and nose when coughing or sneezing
• Stay home from work or school until fever-free and 24 hours after starting antibiotics

By following these preventive measures and seeking prompt treatment when symptoms arise, the spread of strep throat can be significantly reduced.

Long-Term Implications of Untreated Strep Throat

Why is it crucial to treat strep throat promptly? Untreated strep throat can lead to several serious complications:

1. Acute rheumatic fever: An inflammatory disease that can affect the heart, joints, skin, and brain
2. Post-streptococcal glomerulonephritis: A kidney disorder that can occur following a strep infection
3. Peritonsillar abscess: A collection of pus that forms near the tonsils
4. Mastoiditis: An infection of the mastoid bone behind the ear

These potential complications underscore the importance of timely diagnosis and appropriate antibiotic treatment for strep throat.

Understanding the optimal antibiotic choices, proper dosages, and key symptoms of strep throat is essential for effective management of this common bacterial infection. By following evidence-based treatment guidelines and taking preventive measures, patients can recover quickly and reduce the risk of complications and transmission to others.

What is the best antibiotic to treat strep throat?

Medically reviewed by Carmen Pope, BPharm. Last updated on Nov 10, 2022.

Penicillin or amoxicillin are considered the best first-line treatments for Strep throat. According to the CDC (Centers for Disease Control and Prevention) “There has never been a report of a clinical isolate of group A strep that is resistant to penicillin”.

For people with a penicillin allergy, treat Strep throat with either a narrow-spectrum cephalosporin (such as cephalexin or cefadroxil), clindamycin, azithromycin, or clarithromycin. Note that resistance to azithromycin and clarithromycin has been reported.

What are the recommended dosages of antibiotics used to treat Strep throat?

Antibiotic dosages can vary depending on age and weight. The CDC recommends the following dosages of antibiotics for Strep throat, for those people without a penicillin allergy. One dosage regimen should be chosen that is appropriate for the person being treated.

Oral Penicillin V

• Children: 250mg twice daily or 250mg three times daily for 10 days
• Adolescents and adults: 250mg four times daily or 500mg twice daily for 10 days

Oral amoxicillin

• Children and adults: 50 mg/kg once daily (maximum 1000mg once daily) for 10 days
• Children and adults: 25 mg/kg twice daily (maximum 500mg twice daily) for 10 days

Intramuscular Benzathine penicillin G

• Children <27 kg: 600 000 units as a single dose
• Children and adults ≥27 kg: 1 200 000 units as a single dose

The CDC recommends the following dosages of antibiotics for Strep throat, for those people with a penicillin allergy. One dosage regimen should be chosen that is appropriate for the person being treated.

• Oral cephalexin 20 mg/kg twice daily (maximum 500 mg twice daily) for 10 days
• Oral cefadroxil 30 mg/kg once daily (maximum 100mg once daily) for 10 days
• Oral clindamycin 7 mg/kg three times daily (maximum 300 mg three times daily) for 10 days
• Oral azithromycin 12 mg/kg once daily for the first day (maximum 500 mg), followed by 6 mg/kg once daily (maximum 250 mg once daily) for the next 4 days
• Oral clarithromycin 7. 5 mg/kg twice daily (maximum 250 mg twice daily) for 10 days.

Are antibiotics always necessary to treat a Strep throat?

Although most Strep throats will get better by themselves, there is a risk of acute rheumatic fever and other complications (such as oral abscesses or mastoiditis [a bacterial infection in the mastoid process, which is the prominent bone behind the ear]) occurring. The CDC recommends that all patients, regardless of age, who have a positive rapid antigen detection test (RADT) (also known as the rapid streptococcal test, which detects the presence of GABHS cell wall carbohydrate from swabbed material) or throat culture receive antibiotics.

Antibiotics have been shown to:

• Shorten the duration of Strep throat symptoms
• Reduce the likelihood of transmission to family members, friends, and other close contacts
• Prevent the development of rheumatic fever and other complications.

Viral sore throats should not be treated with antibiotics. Treatment is usually given for ten days and liquid antibiotics can be given to children who are unable to swallow tablets or capsules. Some patients may benefit from a single shot of penicillin intramuscularly.

What are the symptoms of a Strep throat?

Generally, Strep sore throats tend to be very painful and symptoms persist for a lot longer than sore throats due to another cause. Swallowing may be particularly difficult and painful. Symptoms of a Strep throat may include:

• Sudden onset of sore throat
• Very red and swollen-looking tonsils and back of the throat
• Sometimes streaks of pus or red spots may appear on the roof of the mouth
• A headache
• Fever and Chills
• Swollen and tender glands (lymph nodes) in the neck.

Children are more likely to feel sick (develop nausea) and vomit.

People with a Strep throat do NOT typically have a cough, runny nose, hoarseness, mouth ulcers, or conjunctivitis. If these symptoms occur there is more likely to be a viral cause for the sore throat.

Some people (usually children aged 4 to 8years) are susceptible to the toxins (poisons) produced by the S. pyrogenes bacteria and develop a bright red rash that feels like sandpaper to the touch. A rash caused by S. pyrogenes bacteria is known as Scarlet Fever (also called scarlatina). Although it usually follows a sore throat, it may also occur after school sores (impetigo).

How is a Strep throat diagnosed?

A throat swab taken by a doctor and then cultured in a laboratory is the only way to definitively tell if a sore throat is a Strep throat. If the result is positive, your doctor will prescribe antibiotics to prevent any complications, reduce symptoms, and prevent spread to other people.

Are Strep throats contagious?

Yes, Strep throats are contagious, and the bacteria are easily transmitted and spread by coughing or sneezing or after coming into contact with infected droplets, and then touching your mouth, nose, or eyes. Transmission of bacteria can also occur via contact with people with Scarlet fever, or other group A skin infections.

Without treatment, people with Strep throat can pass on the bacteria to others for one to two weeks after symptoms appear. The best way to prevent infection is to wash your hands often and always before eating or after being in contact with an infected person. Do not share utensils, linen, or personal items. People with Strep throat or scarlet fever should stay home for at least 24 hours after starting antibiotics or until they feel well enough to return to school or work.

What is scarlet fever?

Scarlet fever is the name given to a bright red rash that develops following a Strep throat, although it can also develop following school sores (impetigo).

Scarlet fever is less common than it was one hundred years ago because of antibiotic use and it only occurs in those who are susceptible to the toxins produced by the Streptococcal bacteria. It mostly occurs in children aged 4 to 8 years. By 10 years old more than 80% of children have developed lifelong protective antibodies against streptococcal toxins, whilst infants younger than 2 still have antibodies against the toxin that they acquired from their mother. This means that if two children in one family develop Strep throat, only one may develop scarlet fever.

Scarlet fever is a bright red rash that feels like sandpaper to the touch. The rash typically starts on the neck, underarm, or groin as small, flat red blotches that gradually become fine bumps and feel rough to the touch. In the body folds (such as in the armpits, elbows, and groin) the rash may appear a brighter red (called Pastia’s lines). Facial flushing is common although a pale area may remain around the mouth. After seven days, the rash fades and some skin peeling may occur over the next month or longer, particularly around the fingertips, toes, and groin area.

Left untreated, Scarlet fever may progress to:

• Ear, sinus, and skin infections
• Joint inflammation
• Rheumatic fever (an inflammatory disease that can cause permanent heart damage and also affect the brain, joints, and skin)
• Otitis media
• Pneumonia
• Septicemia
• Glomerulonephritis
• Osteomyelitis.

In the pre-antibiotic era, death occurred in 15-20% of people with Scarlet fever. Nowadays, most people fully recover within four to five days with antibiotics.

What is Rheumatic Fever?

Rheumatic fever can develop following a Strep throat infection or scarlet fever. Although rare in the contiguous U.S., the disease is still prevalent in children of Samoan descent living in Hawaii and residents of American Samoa.

Symptoms of rheumatic fever usually show 14 to 28 days after a Strep infection. Because the bacteria trick the body’s immune system into attacking healthy tissues, the disease can affect the heart, joints, skin, and brain.

Symptoms of rheumatic fever include:

• Fever
• Abdominal pain
• Chest pain or shortness of breath
• Joint swelling, pain, redness, or warmth
• Nose bleeds
• A rash on the upper part of the arms or legs (usually ring-shaped or snake-like)
• Skin nodules or lumps
• Unusual crying or laughing or quick jerky movements of the face, hands, or feet.

Rheumatic fever has the potential to cause life-long cardiac problems if not treated promptly or properly. Antibiotics are effective at preventing the disease if administered within nine days of symptoms. Children who develop rheumatic fever may need regular penicillin injections until the age of 21 or for 10 years after diagnosis.

References

• Oakley A. Scarlet fever. DermNet NZ. Updated Sept 2015. https://dermnetnz.org/topics/scarlet-fever/#:~:text=Scarlet%20fever%20occurs%20mostly%20in,and%20females%20are%20affected%20equally.
• Pharyngitis (Strep Throat) Centers for Disease Control and Prevention https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html#:~:text=Penicillin%20or%20amoxicillin%20is%20the,is%20common%20in%20some%20communities.

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Medical Disclaimer

Antibiotics – Understand – ReAct

What are antibiotics?

Antibiotics are important medicines for the treatment of bacterial infections in humans and animals. Since their introduction in the 1940’s, antibiotics have saved countless lives and have made many medical procedures possible or safer.

Figure 1. The importance of antibiotics. Antibiotics are used to treat many common infections and save the lives of those at high risk for developing severe infections, such as patients undergoing organ transplantation or cancer treatment.

Difference between antimicrobials and antibiotics

There are many different compounds that can inhibit the growth of microorganisms. ‘Antimicrobials‘, ‘antibacterials’ and ‘antibiotics’ are commonly used terms to define these compounds and often they are used interchangeably, but there are important differences between these words:

• Antimicrobials is a wider term that includes all agents that act against microorganisms, namely bacteria, fungi, viruses and protozoa.

• Antibacterials act only on bacteria. This term broadly defines all compounds that act against bacteria, including antibiotics. Today the term is sometimes used for different types of disinfectants that are not used as medicine, such as alcohol or triclosan.

• Antibiotics are produced naturally by microorganisms and kill or inhibit the growth of other microorganisms, mainly bacteria. The word comes from the Greek words ‘anti’, meaning ‘against’, and ‘biotikos’, meaning ‘concerning life’. Strictly speaking, antibiotics do not include agents that are produced by chemical or biochemical synthesis. However for simplicity, synthetic or semi-synthetic variants (such as quinolones) are usually included under the term antibiotics. In this Toolbox, the term antibiotic is used for naturally produced and synthetic compounds that are active against bacteria, mainly those that have been approved for treatment of bacterial infections in humans and/or animals.

Figure 2. Different types of antimicrobials and the microorganisms they are active against.

Antibiotics act on bacteria, not viruses

Antibiotics are mainly active against bacteria, but can also have activity against for example some parasites. They do not cure infections caused by viruses. Below are some examples of bacterial and viral infections:

Cephalosporins: pharmacological group

Description

Depending on the characteristics of the antimicrobial spectrum, 5 generations of cephalosporins are distinguished.

First generation cephalosporins: parenteral – cefazolin, oral – cephalexin.

II generation cephalosporins: parenteral – cefuroxime, oral – cefuroxime axetil, cefaclor.

III generation cephalosporins: parenteral – cefotaxime, ceftriaxone, cefoperazone, cefoperazone / sulbactam, ceftazidime, oral – cefditoren, cefixime, cefpodoxime, ceftibuten.

IV generation cephalosporins: parenteral – cefepime, cefpirome.

V generation cephalosporins (anti- MRSA -cephems): parenteral – ceftaroline, ceftobiprole.

I generation cephalosporins have predominant activity against gram-positive cocci – staphylococci and streptococci. Gram-negative bacteria are resistant, with the exception of some community-acquired strains E. coli and P. mirabilis. Used for infections of the skin and soft tissues, bones and joints, for perioperative prophylaxis. As an alternative means, it is used for endocarditis and sepsis caused by methicillin-sensitive staphylococci and viridescent streptococci. Cefazolin does not penetrate well through the BBB. Excreted mainly in the urine, T _1/2 – 2 hours, administered 2-3 times a day. Cephalexin has a high oral bioavailability. The main indications for the use of cephalexin: streptococcal pharyngitis, streptococcal and staphylococcal uncomplicated community-acquired infections of the skin and soft tissues.

Second-generation cephalosporins, having activity similar to first-generation cephalosporins against gram-positive cocci, surpass them in their effect on gram-negative bacteria, primarily H. influenzae. Well distributed (except for the central nervous system), excreted mainly by the kidneys, have close T _1/2 (about 1 hour). Used for the treatment of community-acquired infections, for perioperative prophylaxis.

III generation parenteral cephalosporins have a high natural activity against gram-negative bacteria ( family Enterobacteriaceae, H. influenzae, N. gonorrhoeae, N. meningitidis), are not inactivated by many β-lactamases. Degraded by extended spectrum β-lactamases and class C β-lactamases (AmpC). Ceftazidime and cefoperazone are active against P. aeruginosa. In terms of activity against staphylococci, they are significantly inferior to drugs of the first and second generations, but against streptococci and pneumococci, cefotaxime and ceftriaxone are superior to other cephalosporins and act on many penicillin-resistant strains. Ceftazidime is practically inactive against Gram-positive bacteria. All drugs of this group are well distributed in the body, penetrate (except for cefoperazone) through the BBB and can be used to treat infections of the central nervous system. Cefotaxime and ceftazidime are excreted by the kidneys, while cefoperazone and ceftriaxone are excreted by the kidneys and liver. All III generation cephalosporins have similar T _1/2 (1.2-2 hours), except for ceftriaxone (about 7 hours). It is used to treat severe community-acquired and nosocomial infections caused by gram-negative microorganisms. Cefoperazone / sulbactam, a combination of a third-generation cephalosporin with a β-lactamase inhibitor sulbactam, has an extended spectrum of activity compared to cephalosporins, including anaerobes and many nosocomial bacterial strains, incl. most strains producing extended spectrum β-lactamase.

Third-generation oral cephalosporins cefixime and ceftibuten are active against Enterobacteria and Haemophilus influenzae, but are not very active against Gram-positive organisms, including pneumococci, streptococci, and staphylococci; therefore, they should not be used in Gram-positive infections, especially community-acquired pneumonia. Cefditoren, unlike cefixime and ceftibuten, has high activity against staphylococci and streptococci (including pneumococci), and therefore does not have the above limitations.

IV generation cephalosporins are characterized by high activity against Gram-negative bacteria, including P. aeruginosa, and increased activity against Gram-positive flora compared to III generation drugs (ceftazidime). Active against some nosocomial strains Enterobacteriaceae, resistant to III generation cephalosporins. Destroyed by extended spectrum β-lactamases, but resistant to class C β-lactamases. Used to treat severe nosocomial infections, incl. in the intensive care unit and in neutropenic patients. Cefpirome is inferior to cefepime in activity against most pathogens.

Fifth generation cephalosporins (anti- MRSA -cephems) include parenteral preparations ceftaroline and ceftobiprole only. The main distinguishing feature of the 5th generation cephalosporins is the highest activity among β-lactams in vitro against gram-positive bacteria, including most strains MRSA . The activity of ceftaroline and ceftobiprole against gram-negative bacteria is generally equivalent to that of cefotaxime and ceftriaxone.

The most common side effects are allergic reactions. Approximately 10% of patients with hypersensitivity to penicillin have cross-allergic reactions to cephalosporins of the first generation. Cefoperazone can cause hypoprothrombinemia and a disulfiram-like effect.

Macrolides and azalides: pharmacological group

Information for healthcare professionals only.
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• Macrolides and azalides in combinations

• Choice of drugs
• Description
• Synonyms

Description

Macrolides have a bacteriostatic effect and are predominantly active against intracellular pathogens (chlamydia, mycoplasma, legionella) and gram-positive cocci (except MRSA and enterococci). In recent years, activity against pneumococci and streptococci has sharply decreased, which must be taken into account when choosing drugs for respiratory infections. Gram-negative microorganisms of family Enterobacteriaceae, P. aeruginosa and gram-negative anaerobes are naturally resistant to macrolides. Of the other gram-negative bacteria, Moraxella, Bordetella, Neisseria, Campylobacter and Helicobacter show a certain sensitivity to macrolides. Of practical importance is the activity of some macrolides against atypical mycobacteria and protozoa (Toxoplasma). Among macrolides, only azithromycin and clarithromycin have moderate activity against H. influenzae in vitro .

Macrolides are satisfactorily absorbed when taken orally (food reduces bioavailability) and are distributed in many tissues and secretions (poorly penetrate the BBB). Create high tissue and intracellular concentrations. Metabolized in the liver, excreted mainly through the gastrointestinal tract. In renal failure, dose adjustment is not carried out (with the exception of clarithromycin).

The most common adverse reactions are dyspepsia. Allergic reactions are rare. With intravenous administration, phlebitis may develop. Erythromycin in newborns may contribute to the development of pyloric stenosis.

Most drugs (especially erythromycin and clarithromycin) are strong inhibitors of cytochrome P450 isoenzymes, therefore, against the background of their use, intramuscular biotransformation is weakened and the concentration in blood plasma (serum) of drugs metabolized in the liver (including theophylline, warfarin) increases , cyclosporine). It is also possible to prolong the QT interval. Macrolides are used for infections of the upper and lower respiratory tract (mainly caused by “atypical” pathogens), urogenital infections caused by chlamydia and mycoplasmas, and infections of the skin and soft tissues. Erythromycin is the drug of choice for legionellosis, for the prevention of acute rheumatic fever (with an allergy to penicillin) and for intestinal decontamination before colorectal surgery. Clarithromycin is used to treat and prevent opportunistic infections in AIDS caused by certain atypical mycobacteria and to eradicate H. pylori for peptic ulcer of the stomach and duodenum. Spiramycin is used to treat toxoplasmosis, incl. in pregnant women.

Benefits of spiramycin, clarithromycin, azithromycin, roxithromycin, midecamycin and josamycin over erythromycin: improved pharmacokinetics, tolerability and reduced frequency of use. 16-mer macrolides (spiramycin, josamycin and midecamycin) inhibit cytochrome P450 isoenzymes to a lesser extent, do not have prokinetic properties and are active against some strains of streptococci and pneumococci resistant to 14- and 15-mer macrolides.

• macrolides
• antibiotic, azalide
• Antibiotic – macrolide
• antibiotic, macrolide
• Antibiotic azalide
• Antibiotic – azalide
• macrolides and azalides

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