Antibiotic class | Drug | Dosing in children and adolescents* | Advantages | Disadvantages |
Penicillins (preferred) | Penicillin V | - If ≤27 kg: 250 mg 2 to 3 times daily for 10 days
- If >27 kg: 500 mg 2 to 3 times daily for 10 days
| - Narrow spectrum
- No documented resistance
- Low cost
| - Thrice-daily dosing; however, twice-daily regimen appears to be as effective as thrice daily[1]
|
Amoxicillin* | - 50 mg/kg per day orally (maximum 1000 mg per day) for 10 days
- May be administered once daily or in 2 equally divided doses
| - Taste of suspension more palatable than penicillin, often preferred for children
| |
Penicillin G benzathine (Bicillin L-A) | - If ≤27 kg: Penicillin G benzathine (Bicillin L-A) 600,000 units IM as a single dose¶
- If >27 kg: 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 penicillinΔ) | Cephalexin* (first generation) | - 40 mg/kg/day divided twice daily for 10 days (maximum 500 mg/dose)
| - High efficacy rate
- Narrower spectrum than later-generation cephalosporins
| - Broader spectrum than penicillin
- Greater potential to induce antibiotic resistance
|
Cefuroxime* (second generation) | - 10 mg/kg/dose orally twice daily for 10 days (maximum 250 mg/dose)
| - 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) | - 5 mg/kg/dose orally every 12 hours (maximum 100 mg/dose) 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) | - 7 mg/kg/dose orally every 12 hours for 5 to 10 days or 14 mg/kg/dose every 24 hours for 10 days (maximum 600 mg/day)
| - High efficacy rate
- FDA approved for 5-day course when dosed twice daily
| - Broader spectrum than penicillin and earlier-generation cephalosporins
- Greater potential to induce antibiotic resistance
|
Macrolides (alternatives for patients with anaphylaxis or other IgE-mediated reactions or severe delayed reactions to penicillinΔ) | Azithromycin | - 12 mg/kg/day (maximum 500 mg/dose) for 5 days
| - Can be given as a 5-day course due to extended half-life
| - Growing rates of resistance
- Associated with QTc prolongation and, rarely, life-threatening cardiovascular events including TdP; assess risk (eg, history of long QT interval, interacting medications, electrolyte abnormalities)
|
Clarithromycin* | - 7.5 mg/kg/dose (maximum 250 mg per dose) orally twice daily for 10 days
| | - Growing rates of resistance
- Greater gastrointestinal side effects than azithromycin
- Causes CYP3A4 drug interactions
- QTc interval prolongation: Refer to azithromycin
|
Lincosamides (alternative when macrolide resistance is a concern and penicillins and cephalosporins cannot be used) | Clindamycin | - 7 mg/kg/dose (maximum 300 mg per dose) orally 3 times daily for 10 days
| | - Growing rates of resistance
- High side effect profile (ie, gastrointestinal)
|