Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – antibiotic therapy

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all patients
1st line – 

antibiotic therapy

Treatment recommendations and availability of antibiotics varies across countries. Refer to your local protocol for specific guidance in your area. The following guidance is in line with guidance from the UK Health Security Agency (UKHSA).[25]

Prescribe antibiotics promptly to patients with a suspected (presence of the triad of sore throat, fever and a scarlatiniform rash) or confirmed diagnosis of scarlet fever, regardless of the severity of illness.[25] Prompt initiation of antibiotics significantly reduces the risk of complications such as rheumatic fever and invasive group A streptococcus (GAS) infection.[25]

In the UK, test confirmation of GAS infection is not required prior to the initiation of antibiotics. However, a throat swab for GAS culture can be considered in some patients before starting treatment, but without waiting for the culture result if scarlet fever is clinically suspected.[25] See Diagnosis. In countries where rapid antigen detection tests for scarlet fever are available, a positive test result may be required before starting antibiotics.

Give phenoxymethylpenicillin to patients with no history of penicillin allergy:[2][3][25][48]

  • Oral phenoxymethylpenicillin for 10 days is the treatment of choice in children and adults.[2][3][25][49][50]​​

For patients who are allergic to penicillin, give:[25]

  • Clarithromycin for 10 days: from birth to 6 months of age

  • Azithromycin for 5 days: from 6 months to adult (non-pregnant)

  • Erythromycin for 10 days: in pregnant or postnatal (within 28 days of childbirth) women.

Have a low threshold for prompt referral to secondary care of any child presenting with persistent or worsening symptoms, particularly in regions in which an outbreak is ongoing.

Primary options

phenoxymethylpenicillin: children <1 month of age: consult specialist for guidance on dose; children 1-11 months of age: 62.5 mg orally four times daily for 10 days; children 1-5 years of age: 125 mg orally four times daily for 10 days; children 6-11 years of age: 250 mg orally four times daily for 10 days; children ≥12 years of age and adults: 250-500 mg orally four times daily for 10 days

Secondary options

azithromycin: children 6 months to 11 years of age: 12 mg/kg orally once daily for 5 days, maximum 500 mg/day; children ≥12 years of age and adults: 500 mg orally once daily for 5 days

OR

clarithromycin: children <1 month of age: 7.5 mg/kg orally (immediate-release) twice daily for 10 days; children 1-6 months of age (≤8 kg body weight) 7.5 mg/kg orally (immediate-release) twice daily for 10 days; children 1-6 months of age (8-11 kg body weight) 62.5 mg orally (immediate-release) twice daily for 10 days

OR

erythromycin base: adults: 250-500 mg orally four times daily for 10 days, or 500-1000 mg orally twice daily for 10 days

Plus – supportive care

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ACUTE
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all patients
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Advise patients to rest, drink plenty of fluids, and practise good hygiene measures to minimise the risk of cross-infection.[23][53]

Give analgesics/antipyretics to treat moderate to severe symptoms of acute pharyngitis such as sore throat, headache, and fever. Paracetamol and ibuprofen are appropriate options.[2][23]

In practice, consider:

  • Oral antihistamines (e.g., diphenhydramine, loratadine, cetirizine) or over-the-counter topical emollient ointments and thick creams for patients with significant pruritus associated with the scarlatiniform rash

  • Advising patients with pyoderma (impetigo) to keep the infected area clean and protected with dressings. Twice-daily washing with soap and water is good general skin care. In severe cases, debridement of the infected skin may be required.

Primary options

Analgesic/antipyretic

paracetamol: children: consult product literature for guidance on dose; adults: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

Analgesic/antipyretic

ibuprofen: children ≥6 months of age: 5-10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; children ≥12 years of age and adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

OR

Antihistamine

diphenhydramine: children <6 years of age: consult specialist for guidance on dose; children ≥6 years of age: 12.5 to 25 mg orally every 4-6 hours when required, maximum 150 mg/day; children ≥12 years of age and adults: 25-50 mg orally every 4-6 hours when required, maximum 300 mg/day

OR

Antihistamine

loratadine: children 2-5 years of age: 5 mg orally once daily when required; children ≥6 years of age and adults: 10 mg orally once daily when required

OR

Antihistamine

cetirizine: children 6-11 months of age: 2.5 mg orally once daily when required; children 12-23 months of age: 2.5 mg orally once or twice daily when required; children 2-5 years of age: 2.5 to 5 mg/day orally given in 1-2 divided doses; children ≥6 years of age and adults: 5-10 mg orally once daily when required

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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