Penicillin has a narrow spectrum of activity and is the least expensive regimen. Penicillin may be administered intra-muscularity or orally depending on the physicians assessment of the patient's likely adherence to an oral regimen and the risks of rheumatic fever in a particular population. Amoxicillin may have a better compliance because of superior palatability, however, it is reported to have no microbiologic advantage over the less expensive penicillin. All patients should continue to take penicillin regularly for an entire 10 day period even though they will likely be asymptomatic after the first few days. Patients are considered non contagious 24 hours after the initiation of therapy.
Oral erythromycin is an acceptable alternative for patients allergic to penicillin.
Azithromycin can be administered once a day, producing high tonsillar tissue concentrations. All other erythromycins should be prescribed for 10 days. A 10 day course of an oral cephalosporin is also considered to be an acceptable alternative particularly for penicillin-allergic individuals. Although recent reports suggests that a 5 day course may be as effective as a 10 day course this is not the current recommendation at this time. The advantage of cephalosoporins in treating beta-lactamase producing upper respiratory flora which may interfere with penicillin is a theoretical consideration and remains controversial at this time.