Practice Guidelines

IDSA Updates Guideline for Managing Group A Streptococcal Pharyngitis



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Am Fam Physician. 2013 Sep 1;88(5):338-340.

Guideline source: Infectious Diseases Society of America

Evidence rating system used? Yes

Literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? No

Published source: Clinical Infectious Diseases, September 2012

Available at: http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.full.pdf+html

The Infectious Diseases Society of America (IDSA) has updated its 2002 guideline on managing group A streptococcal pharyngitis. The illness primarily occurs in children five to 15 years of age. Patients typically present with sudden onset of a sore throat, pain with swallowing, and fever. Examination shows tonsillopharyngeal erythema, often with lymphadenitis. The symptoms of streptococcal pharyngitis often overlap with those of viral pharyngitis, and the two cannot be differentiated using clinical features alone unless overt viral features are present.

Diagnosis

Clinical features of group A streptococcal pharyngitis and viral pharyngitis are listed in Table 1. Diagnosis of group A streptococcal pharyngitis should be confirmed using a rapid antigen detection test and/or culture of a throat swab.

Table 1.

Features Suggestive of Group A Streptococcal and Viral Pharyngitis

Group A streptococcal infection

Sudden onset of sore throat

Age 5 to 15 years

Fever

Headache

Nausea, vomiting, abdominal pain

Tonsillopharyngeal inflammation

Patchy tonsillopharyngeal exudates

Palatal petechiae

Anterior cervical adenitis (tender nodes)

Presentation in winter or early spring

History of exposure to streptococcal pharyngitis

Scarlatiniform rash

Viral infection

Conjunctivitis

Coryza

Cough

Diarrhea

Hoarseness

Discrete ulcerative stomatitis

Viral exanthem


Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e91.

Table 1.   Features Suggestive of Group A Streptococcal and Viral Pharyngitis

View Table

Table 1.

Features Suggestive of Group A Streptococcal and Viral Pharyngitis

Group A streptococcal infection

Sudden onset of sore throat

Age 5 to 15 years

Fever

Headache

Nausea, vomiting, abdominal pain

Tonsillopharyngeal inflammation

Patchy tonsillopharyngeal exudates

Palatal petechiae

Anterior cervical adenitis (tender nodes)

Presentation in winter or early spring

History of exposure to streptococcal pharyngitis

Scarlatiniform rash

Viral infection

Conjunctivitis

Coryza

Cough

Diarrhea

Hoarseness

Discrete ulcerative stomatitis

Viral exanthem


Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e91.

A positive result on rapid antigen detection testing is diagnostic for group A streptococcal pharyngitis. A backup culture should be performed in children and adolescents with negative test results. A backup culture generally is not necessary in adults because the incidence of the illness and the risk of subsequent rheumatic fever are low in adults; however, it can be considered. Antistreptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis.

Diagnostic testing is not recommended if clinical features strongly suggest a viral etiology (e.g., cough, rhinorrhea, hoarseness, oral ulcers). Testing is generally not recommended in children younger than three years unless the child has risk factors, such as an older sibling with the illness, because the illness is uncommon in this age group. Follow-up posttreatment testing is not routinely recommended, but may be considered. Testing of household contacts of patients with group A streptococcal pharyngitis is not routinely recommended.

Treatment

Patients with acute group A streptococcal pharyngitis should be treated with an antibiotic that is likely to eradicate the organism, usually for 10 days. Penicillin or amoxicillin is commonly recommended because of its narrow spectrum of activity, few adverse effects, and modest cost. Alternative antibiotics for those with penicillin allergy include a first-generation cephalosporin, clindamycin, clarithromycin (Biaxin), or azithromycin (Zithromax). Table 2 summarizes antibiotic regimens for patients with and without penicillin allergy.

Table 2.

Treatment Regimens for Group A Streptococcal Infection

Drug Dose/dosage Duration Recommendation strength, quality of evidence

Patients without penicillin allergy

Penicillin V, oral

Children: 250 mg two or three times daily

10 days

Strong, high

Adolescents and adults: 250 mg four times daily or 500 mg twice daily

Amoxicillin, oral

50 mg per kg once daily (maximum = 1,000 mg)

10 days

Strong, high

Alternative: 25 mg per kg twice daily (maximum= 500 mg)

Penicillin G benzathine, intramuscular

< 60 lb (27 kg): 600,000 U

Single dose

Strong, high

≥ 60 lb: 1,200,000 U

Patients with pencillin allergy

Cephalexin (Keflex), oral*

20 mg per kg per dose twice daily (maximum = 500 mg per dose)

10 days

Strong, high

Cefadroxil, oral*

30 mg per kg once daily (maximum = 1 g)

10 days

Strong, high

Clindamycin, oral

7 mg per kg per dose three times daily (maximum = 300 mg per dose)

10 days

Strong, moderate

Azithromycin (Zithromax), oral†

12 mg per kg once daily (maximum = 500 mg)

5 days

Strong, moderate

Clarithromycin (Biaxin), oral†

7.5 mg per kg per dose twice daily (maximum = 250 mg per dose)

10 days

Strong, moderate


*—Avoid in individuals with immediate hypersensitivity to penicillin.

†—Resistance of group A streptococcus to these agents is well-known and varies geographically and temporally.

Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e89.

Table 2.   Treatment Regimens for Group A Streptococcal Infection

View Table

Table 2.

Treatment Regimens for Group A Streptococcal Infection

Drug Dose/dosage Duration Recommendation strength, quality of evidence

Patients without penicillin allergy

Penicillin V, oral

Children: 250 mg two or three times daily

10 days

Strong, high

Adolescents and adults: 250 mg four times daily or 500 mg twice daily

Amoxicillin, oral

50 mg per kg once daily (maximum = 1,000 mg)

10 days

Strong, high

Alternative: 25 mg per kg twice daily (maximum= 500 mg)

Penicillin G benzathine, intramuscular

< 60 lb (27 kg): 600,000 U

Single dose

Strong, high

≥ 60 lb: 1,200,000 U

Patients with pencillin allergy

Cephalexin (Keflex), oral*

20 mg per kg per dose twice daily (maximum = 500 mg per dose)

10 days

Strong, high

Cefadroxil, oral*

30 mg per kg once daily (maximum = 1 g)

10 days

Strong, high

Clindamycin, oral

7 mg per kg per dose three times daily (maximum = 300 mg per dose)

10 days

Strong, moderate

Azithromycin (Zithromax), oral†

12 mg per kg once daily (maximum = 500 mg)

5 days

Strong, moderate

Clarithromycin (Biaxin), oral†

7.5 mg per kg per dose twice daily (maximum = 250 mg per dose)

10 days

Strong, moderate


*—Avoid in individuals with immediate hypersensitivity to penicillin.

†—Resistance of group A streptococcus to these agents is well-known and varies geographically and temporally.

Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e89.

Adjunctive therapy with an analgesic or antipyretic (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs) can be considered to treat moderate to severe symptoms or control a high fever. Aspirin should not be used in children, and adjunctive corticosteroids are not recommended in the treatment of group A streptococcal pharyngitis.

Patients with recurrent pharyngitis and laboratory evidence of group A streptococcus may be chronic carriers who are having repeated viral infections. Antibiotics are not generally recommended in this case, but may be considered in the following situations: (1) during a community outbreak of acute rheumatic fever, acute poststreptococcal glomerulonephritis, or invasive group A streptococcal infection; (2) during an outbreak of group A streptococcal pharyngitis in a closed or partially closed community; (3) when the patient has a family or personal history of acute rheumatic fever; (4) when the patient or family has excessive anxiety about group A streptococcal infections; or (5) when tonsillectomy is being considered only because the patient is a chronic carrier.

Other antibiotic regimens have been shown to be substantially more effective than penicillin or amoxicillin alone in eliminating chronic streptococcal carriage. Table 3 summarizes the treatment options.

Table 3.

Treatment Regimens for Chronic Carriers of Group A Streptococcus

Drug Dose/dosage Duration Recommendation strength,quality of evidence

Clindamycin, oral

20 to 30 mg per kg per day in three doses (maximum = 300 mg per dose)

10 days

Strong, high

Penicillin and rifampin, oral

Penicillin V: 50 mg per kg per day in four doses for 10 days (maximum = 2,000 mg per day)

10 days

Strong, high

Rifampin: 20 mg per kg per day in one dose for last four days of treatment (maximum = 600 mg per day)

Amoxicillin/clavulanate (Augmentin), oral

40 mg amoxicillin per kg per day in three doses (maximum = 2,000 mg amoxicillin per day)

10 days

Strong, moderate

Penicillin G benzathine (intramuscular) and rifampin (oral)

Penicillin G benzathine: < 60 lb (27 kg): 600,000 U; ≥ 60 lb: 1,200,000 U

Penicillin G benzathine: single dose

Strong, high

Rifampin: 20 mg per kg per day in two doses (maximum = 600 mg per day)

Rifampin: four days


Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e98.

Table 3.   Treatment Regimens for Chronic Carriers of Group A Streptococcus

View Table

Table 3.

Treatment Regimens for Chronic Carriers of Group A Streptococcus

Drug Dose/dosage Duration Recommendation strength,quality of evidence

Clindamycin, oral

20 to 30 mg per kg per day in three doses (maximum = 300 mg per dose)

10 days

Strong, high

Penicillin and rifampin, oral

Penicillin V: 50 mg per kg per day in four doses for 10 days (maximum = 2,000 mg per day)

10 days

Strong, high

Rifampin: 20 mg per kg per day in one dose for last four days of treatment (maximum = 600 mg per day)

Amoxicillin/clavulanate (Augmentin), oral

40 mg amoxicillin per kg per day in three doses (maximum = 2,000 mg amoxicillin per day)

10 days

Strong, moderate

Penicillin G benzathine (intramuscular) and rifampin (oral)

Penicillin G benzathine: < 60 lb (27 kg): 600,000 U; ≥ 60 lb: 1,200,000 U

Penicillin G benzathine: single dose

Strong, high

Rifampin: 20 mg per kg per day in two doses (maximum = 600 mg per day)

Rifampin: four days


Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e98.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

A collection of Practice Guidelines published in AFP is available at http://www.aafp.org/afp/practguide.



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