Diagnosis and Management of Group A Streptococcal Pharyngitis

Publication Date: September 9, 2012
Last Updated: September 2, 2022

Diagnosis

In children and adolescents, negative RADT tests should be backed up by a throat culture. (SR, H)
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Positive RADTs do not necessitate a back-up culture because they are highly specific. (SR, H)
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Routine use of back up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances because there is a low incidence of GAS pharyngitis in adults and the risk of subsequent acute rheumatic fever is generally exceptionally low in adults with acute pharyngitis. (SR, M)
Physicians who wish to ensure they are achieving maximal sensitivity in diagnosis may continue to use conventional throat culture or to back up negative RADTs.
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Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis since they reflect past but not current events. (SR, H)
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Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiologic features that strongly suggest a viral etiology (e.g., cough, rhinorrhea, hoarseness, and oral ulcers). (SR, H)
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Diagnostic studies for GAS pharyngitis are not indicated for children < 3 years old because acute rheumatic fever is rare in these children and the incidence of streptococcal pharyngitis and the classic presentation of streptococcal pharyngitis are uncommon in this age group.
Selected children < 3 years old who have other risk factors such as an older sibling with GAS infection may be considered for testing. (SR, M)
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Follow-up post-treatment throat culture or RADT is not recommended routinely but may be considered in special circumstances. (SR, H)
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Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended. (SR, M)
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Treatment

Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days).
Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those not allergic to these agents. (SR, H)
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Treatment of GAS pharyngitis in penicillin-allergic individuals should include a first generation cephalosporin (for those not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days. (SR, M)
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Adjunctive therapy may be useful in the management of GAS pharyngitis.
If warranted, use of an analgesic/antipyretic agent such as acetaminophen or an NSAID for treatment of moderate to severe symptoms or control of high fever associated with GAS pharyngitis should be considered as an adjunct to an appropriate antibiotic. (SR, H)
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Aspirin should be avoided in children. (SR, M)
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Adjunctive therapy with a corticosteroid is NOT recommended. (WR, M)
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The IDSA recommends that clinicians caring for patients with recurrent episodes of pharyngitis associated with laboratory evidence of GAS pharyngitis consider that they may be experiencing >1 episode of bona fide streptococcal pharyngitis at close intervals, but they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections. (SR, M)
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The IDSA recommends that identifying GAS carriers is not ordinarily justified, nor do GAS carriers generally require antimicrobial therapy, because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or non-suppurative complications (e.g., acute rheumatic fever). (SR, M)
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The IDSA does NOT recommend tonsillectomy solely to reduce the frequency of GAS pharyngitis. (SR, H)
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Table 3. Antibiotic Regimens Recommended for Group A Streptococcal Pharyngitis

Penicillin V generic, oral (SR, H)
Dose:
  • Children: 250 mg bid or tid
  • Adolescents tid
  • Adults: 250 mg qid or 500 mg bid
Duration: 10 days
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Amoxicillin generic, oral (SR, H)
Dose:
  • 50 mg/kg once daily (Max = 1000 mg)
  • Alternate: 25 mg/kg bid
  • (Max = 500 mg) bid
Duration: 10 days
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Benzathine penicillin G generic, IM (SR, H)
Dose:
  • < 27 kg: 600,000 units
  • ≥ 27 kg: 1.2 million units
Duration: one dose
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For Penicillin-Allergic Individuals

Cephalexin Keflex® aPO (SR, H)
Dose:
  • 20 mg/kg/dose bid
  • (Max = 500 mg/dose)
Duration: 10 days
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Cefadroxila Duricef®, Ultracef® PO (SR, H)
Dose:
  • 30 mg/kg daily
  • (Max = 1 gm)
Duration: 10 days
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Clindamycin Cleocin® PO (SR, M)
Dose:
  • 7 mg/kg/dose tid
  • (Max = 300 mg/dose)
Duration: 10 days
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Azithromycinb Zithromax® PO (SR, M)
Dose:
  • 12 mg/kg daily (Max = 500 mg)
Duration: 5 days
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Clarithromycinb Biaxin® PO (SR, M)
Dose:
  • 7.5 mg/kg/dose bid
  • (Max = 250 mg/dose)
Duration: 10 days
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a Avoid in those with immediate type hypersensitivity to penicillin.
Resistance of bGAS to these agents is well-known and varies geographically and temporally.

Table 4. Treatment Regimens for Chronic GAS Carriers

Oral

Clindamycin Cleocin® (SR, H)
Dose:
  • 20-30 mg/kg/d30 mg/kg/d30 mg/kg/d in 3 doses
  • (Max = 300 mg/dose)
Duration: 10 days
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Penicillin and Rifampin
Rifadin®, Rimactane® (SR, H)
Dose:
  • Penicillin and Rifampin
  • Rifadin®, Rimactane®
Duration: 10 days
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Amoxicillin-clavulanic acid Augmentin® (SR, M)
Dose:
  • 40 mg amoxicillin /kg/d40 mg amoxicillin /kg/d40 mg amoxicillin /kg/d in 3 doses
  • (Max = 2000 mg amoxicillin/d)
Duration: 10 days
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IM & Oral

Benzathine penicillin G PLUS Rifampin (SR, H)
Penicillin Dose:
  • 600,000 units for < 27 kg
  • 1,200,000 units for ≥ 27 kg
Duration: one dose

Rifampin Dose:
  • 20 mg/kg/d 20 mg/kg/d 20 mg/kg/d 20 mg/kg/d in 2 doses
  • (Max = 600 mg/d)
Duration: 4 days
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Recommendation Grading

Overview

Title

Diagnosis and Management of Group A Streptococcal Pharyngitis

Authoring Organization

Infectious Diseases Society of America

Publication Month/Year

September 9, 2012

Last Updated Month/Year

November 25, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

Group A streptococcal (GAS) pharyngitis is a significant cause of community-associated infections. This document constitutes a revision of the 2002 guideline of the Infectious Diseases Society of America (IDSA) on the treatment of GAS pharyngitis. The primary objective of this guideline is to provide recommendations on the management of this very common clinical condition among adult and pediatric patients. The guideline addresses issues related to the diagnosis of streptococcal pharyngitis and its treatment in patients who are or are not allergic to penicillin. The guideline does not discuss active surveillance testing or other prevention strategies. Each section of the guideline begins with a specific clinical question and is followed by numbered recommendations and a summary of the most-relevant evidence in support of the recommendations. Areas of controversy in which data are limited or conflicting and in which additional research is needed are indicated throughout the document and are highlighted in the Future Research section.

Target Patient Population

Adult and pediatric patients with group A streptococcal (GAS)

PICO Questions

  1. How should the diagnosis of GAS pharyngitis be established?

  2. Who should undergo testing for GAS pharyngitis?

  3. What are the treatment recommendations for patients with a diagnosis of GAS pharyngitis?

  4. Should adjunctive therapy with NSAIDs, acetaminophen, aspirin, or corticosteroids be given to patients with a diagnosis of GAS pharyngitis?

  5. Is the patient with frequent recurrent episodes of apparent GAS pharyngitis likely to be a chronic pharyngeal carrier of GAS?

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D010612 - Pharyngitis, D013290 - Streptococcal Infections

Keywords

pharyngitis, sore throat, streptococcal, pharyngotonsillitis

Source Citation

Clinical Practice Guidelines for the Diagnosis and Management Of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C.