Antibiotic class | Drug | Dosing in adults* | Advantages | Disadvantages |
Penicillins (preferred) | Penicillin V |
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Amoxicillin¶ |
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Penicillin G benzathine* (Bicillin L-A) |
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Cephalosporins (potential alternatives for mild reactions to penicillinΔ) | Cephalexin* (first generation) |
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Cefadroxil* (first generation) |
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Cefuroxime* (second generation) |
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Cefpodoxime* (third generation) |
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Cefdinir* (third generation) |
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Macrolides (alternatives for patients with anaphylaxis or other IgE-mediated reactions or severe delayed reactions to penicillinΔ) | Azithromycin |
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Clarithromycin* |
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Lincosamides (alternative when macrolide resistance is a concern and penicillins and cephalosporins cannot be used) | Clindamycin§ |
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FDA: US Food and Drug Administration; IM: intramuscularly; TdP: torsades de pointes.
* Dose alteration may be needed for renal insufficiency.
¶ Once-daily immediate-release amoxicillin appears to be non-inferior to penicillin V or amoxicillin administered in multiple daily doses, primarily based on studies in children and adolescents.
Δ Approach to patients with penicillin allergy varies among experts and allergy severity; refer to the UpToDate text for additional detail.
◊ A 3-day course dosed at 500 mg daily is approved and widely prescribed in Europe and other regions. It appears to be more effective than the 5-day course when dosed as 500 mg on day 1 followed by 250 mg daily on days 2 through 5.
§ Rates of resistance to clindamycin are high and can be higher than rates of resistance to macrolides. Therefore, when beta-lactams and macrolides cannot be used, knowledge of local resistance rates should guide antibiotic selection or culture with susceptibility testing should be obtained.Data from:
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