We wish to highlight that oral amoxicillin is as valid a first-line treatment for GAS pharyngitis as oral penicillin V in the National Heart Foundation sore throat management guidelines for New Zealand.1,2
Oral penicillin V 500 mg bd for adults, and 20 mg/kg/day for children (in 2-3 divided doses) is long-established in the international literature and guidelines as first-line treatment for Group A Streptococcal pharyngitis.1,2 However, once-daily oral amoxicillin has emerged as a good alternative, with at least three studies3-5 finding ten-day oral courses of once-daily amoxicillin and penicillin V (2- to 4-times daily) to be equivalent for GAS pharyngitis. Further details of these studies can be seen in the National Heart Foundation’s sore throat guidelines.2 †
While it is very effective, oral penicillin has appreciable disadvantages. It is less palatable6,8 and needs to be given on an empty stomach, three or so times each day, all which can cause considerable difficulties for many patients and caregivers. Conversely with once-daily amoxicillin, although its evidence for GAS eradication comes from hundreds not thousands of patients,9 a single dose without coordinating around mealtimes will suit many patients and families and may help substantially improve adherence. Many families will find it more convenient to take the antibiotics with their food, and the amoxicillin option avoids trying to dose children with a worse-tasting medicine multiple times throughout the day while strictly on an empty stomach.
Once-daily amoxicillin has now been added as a treatment alternative in some other GAS sore throat treatment guidelines internationally, such as the American Academy of Pediatrics' Red Book10 and those of the American Heart Association.11
Oral amoxicillin can be given for 10 days at a dose of 750 mg once daily for children weighing <30 kg, and 1500 mg once daily for children weighing >30 kg2 (which equates to 15 ml per day of 250 mg/5 ml oral liquid, or three 250 or 500 mg capsules, depending on weight).
Previous communication in the Journal1 may have inadvertently understated the positive role of once-daily amoxicillin in GAS eradication and thus rheumatic fever control. As pointed out previously in the Journal,1 there is a need for some caution with amoxicillin and it will not be suitable for all cases of GAS pharyngitis. It should not be used when infectious mononucleosis (IM)/ Epstein Barr Virus (EBV) is suspected (see footnote *), or if a chance a patient may miss any daily dose (for those at high risk for rheumatic fever). However, amoxicillin still has some important advantages. In line with guidelines elsewhere,10,11 we encourage its use in the New Zealand epidemic setting12 alongside oral penicillin as the first-line options.
Professor of Population Child & Youth Health / Paediatrician in Infectious Diseases
University of Auckland / Starship Children’s Hospital
Public Health Medicine Registrar
Professor and Head of General Practice & Primary Health Care
University of Auckland
The National Heart Foundation of New Zealand
- If there is doubt that it will be taken every day.13
- If infectious mononucleosis (IM)/ Epstein Barr Virus (EBV) rather than GAS is suspected as the cause of sore throat.14
Sign or symptom
age 4+ yrs
sore throat or tonsillopharyngitis
cough or rhinitis
abdominal pain or discomfort