Medical Management

Pearls of Wisdom: Strep Throat Dilemmas

Sarah, an 8-year-old girl with a sore throat, has a positive rapid strep test and a history of strep contact. While many antibiotics can effectively treat strep, which one is associated with the lowest rate of posttreatment recurrence?

A. Penicillin
B. Amoxicillin
C. A first-generation cephalosporin
D. A second- or third-generation cephalosporin

What is the correct answer?
(Answer and discussion on next page)

Louis Kuritzky, MD, has been involved in medical education since the 1970s. Drawing upon years of clinical experience, he has crafted each year for almost 3 decades a collection of items that are often underappreciated by clinicians, yet important for patients. These “Pearls of Wisdom” often highlight studies that may not have gotten traction within the clinical community and/or may have been overlooked since their time of publishing, but warrant a second look.

Answer: A second- or third-generation cephalosporin

For nearly 50 years, the American Heart Association has recommended penicillin as the preferred treatment for strep throat infection, so why should we consider other agents?

The Research

In a study comparing the efficacy of penicillin, amoxicillin, and cephalosporin, researchers examined the rates of symptom recurrence among children with group A β-hemolytic streptococcal (GABHS) tonsillopharyngitis. All of the patients (N=4278) had strep infection confirmed with a positive rapid strep test result or a positive throat culture, and all had returned for treatment of recurring symptoms within 20 days after completing antibiotic therapy.

The Results

Overall, 8% of the pediatric patients who took penicillin, 6% who took amoxicillin, 2% who took a first-generation cephalosporin, and 1% who took a second- or third- generation cephalosporin returned with recurrent symptoms within 5 days after finishing the antibiotic regimen.

GABHS Symptomatic Recurrences

GABHS Symptomatic Recurrences

After 6 to 20 days, 16% of those who took penicillin, 14% of those who took amoxicillin, 9% who took a first-generation cephalosporin, and 7% who took a second- or third-generation cephalosporin returned for treatment of recurrent symptoms.

GABHS Symtpmatic Recurrences

What’s The “Take-Home”?

So what can we conclude from these results? A number of voices have suggested that because cephalosporins are relatively inexpensive, we might select a second- or third-generation cephalosporin as initial therapy for strep throat instead of a penicillin or amoxicillin to reduce the likelihood of symptomatic recurrence.


Casey JR, Raymond K, Gmoser D, et al. Frequency of symptomatic relapses of group A β-hemolytic streptococcal tonsillopharyngitis in children from 4 pediatric practices following penicillin, amoxicillin, and cephalosporin antibiotic treatment. Clin Pediatr (Phila). 2008;47(6):549-554.