Common Questions About Streptococcal Pharyngitis

 


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Group A beta-hemolytic streptococcal (GABHS) infection causes 15% to 30% of sore throats in children and 5% to 15% in adults, and is more common in the late winter and early spring. The strongest independent predictors of GABHS pharyngitis are patient age of five to 15 years, absence of cough, tender anterior cervical adenopathy, tonsillar exudates, and fever. To diagnose GABHS pharyngitis, a rapid antigen detection test should be ordered in patients with a modified Centor or FeverPAIN score of 2 or 3. First-line treatment for GABHS pharyngitis includes a 10-day course of penicillin or amoxicillin. Patients allergic to penicillin can be treated with first-generation cephalosporins, clindamycin, or macrolide antibiotics. Nonsteroidal anti-inflammatory drugs are more effective than acetaminophen and placebo for treatment of fever and pain associated with GABHS pharyngitis; medicated throat lozenges used every two hours are also effective. Corticosteroids provide only a small reduction in the duration of symptoms and should not be used routinely.

Pharyngitis is diagnosed in 11 million persons in the outpatient setting each year in the United States.1 Although most episodes are caused by viruses, group A beta-hemolytic streptococcal (GABHS) infection accounts for approximately 15% to 30% of sore throats in children and 5% to 15% in adults.1 Approximately 80% of these episodes are diagnosed in the primary care setting.2 This article reviews common questions about GABHS pharyngitis and provides evidence-based answers.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should diagnose GABHS pharyngitis using an approach that combines a validated clinical decision rule (e.g., modified Centor score, FeverPAIN score) with selective use of rapid antigen detection testing.

A

1, 21, 22

Penicillin is the first-line antibiotic for treating GABHS pharyngitis.

A

22, 24, 28, 32

Symptomatic treatment of GABHS pharyngitis can include medicated throat lozenges, nonsteroidal anti-inflammatory drugs, and topical anesthetics.

B

3, 35, 36, 38, 39


GABHS = group A beta-hemolytic streptococcal.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Physicians should diagnose GABHS pharyngitis using an approach that combines a validated clinical decision rule (e.g., modified Centor score, FeverPAIN score) with selective use of rapid antigen detection testing.

A

1, 21, 22

Penicillin is the first-line antibiotic for treating GABHS pharyngitis.

A

22, 24, 28, 32

Symptomatic treatment of GABHS pharyngitis can include medicated throat lozenges, nonsteroidal anti-inflammatory drugs, and topical anesthetics.

B

3, 35, 36, 38, 39


GABHS = group A beta-hemolytic streptococcal.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Who Is at Increased Risk of GABHS Pharyngitis?

In patients with sore throat, the likelihood of GABHS pharyngitis is highest in children five to 15 years of age (37%) and lower in younger children (24%) and adults (5% to 15%).1,3,4 It is more common in late winter and early spring.1,5

EVIDENCE SUMMARY

Several risk factors should increase the index of suspicion for GABHS pharyngitis. Children five to 15 years of age who have been exposed in the past 72 hours to someone with GABHS infection are at highest risk.1,3,4 The incubation period for GABHS infection is 24 to 72 hours.1 A 2010 meta-analysis found that symptomatic children five to 15 years of age are more likely to have throat cultures positive for GABHS infection compared with younger children (37% vs. 24%).6 Additionally, 2012 guidelines from the Infectious Diseases Society of America (IDSA) indicate that GABHS infection is uncommon in children younger than three years.3 The prevalence of acute pharyngitis secondary to GABHS infection in adults ranges from 5% to 15%.1,3 GABHS pharyngitis is more common in late winter and early spring.1,5 Although contact with GABHS

The Authors

show all author info

MONICA G. KALRA, DO, is teaching faculty for the Memorial Family Medicine Residency in Sugar Land, Tex., and a clinical assistant professor at Texas A&M College of Medicine and Baylor College of Medicine. ...

KIM E. HIGGINS, DO, is medical director of Envoy Hospice and Brookdale Hospice, Fort Worth, Tex., and is in private practice at Physician Senior Services in Fort Worth.

EVAN D. PEREZ, MD, is a second-year resident at Memorial Family Medicine Residency.

Address correspondence to Monica G. Kalra, DO, Memorial Family Medicine Residency, 14023 Southwest Freeway, Sugar Land, TX 77478 (e-mail: monica.kalra@memorialhermann.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Choby BA. Diagnosis and treatment of streptococcal pharyngitis [published correction appears in Am Fam Physician. 2013;88(4):222]. Am Fam Physician. 2009;79(5):383–390....

2. Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. National Health Statistics Reports. http://www.cdc.gov/nchs/data/nhsr/nhsr008.pdf. Accessed March 8, 2016.

3. 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 [published correction appears in Clin Infect Dis. 2014;58(10):1496]. Clin Infect Dis. 2012;55(10):e86–e102.

4. Wessels MR. Clinical practice. Streptococcal pharyngitis. N Engl J Med. 2011;364(7):648–655.

5. Fine AM, Nizet V, Mandl KD. Participatory medicine: a home score for streptococcal pharyngitis enabled by real-time biosurveillance: a cohort study. Ann Intern Med. 2013;159(9):577–583.

6. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics. 2010;126(3):e557–e564.

7. Tanz RR, Shulman ST. Chronic pharyngeal carriage of group A streptococci. Pediatr Infect Dis J. 2007;26(2):175–176.

8. Pichichero ME, Marsocci SM, Murphy ML, Hoeger W, Green JL, Sorrento A. Incidence of streptococcal carriers in private pediatric practice. Arch Pediatr Adolesc Med. 1999;153(6):624–628.

9. Linder JA, Chan JC, Bates DW. Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic. Arch Intern Med. 2006;166(13):1374–1379.

10. Ebell MH, Smith MA, Barry HC, Ives K, Carey M. The rational clinical examination. Does this patient have strep throat? JAMA. 2000;284(22):2912–2918.

11. Little P, Hobbs FD, Moore M, et al.; PRISM Investigators. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ. 2013;347:f5806.

12. Cirilli AR. Emergency evaluation and management of the sore throat. Emerg Med Clin North Am. 2013;31(2):501–515.

13. Son KH, Shin MY. Clinical features of Epstein-Barr virus-associated infectious mononucleosis in hospitalized Korean children. Korean J Pediatr. 2011;54(10):409–413.

14. Rea TD, Russo JE, Katon W, Ashley RL, Buchwald DS. Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr virus. J Am Board Fam Pract. 2001;14(4):234–242.

15. Yin XG, Yi HX, Shu J, Wang XJ, Wu XJ, Yu LH. Clinical and epidemiological characteristics of adult hand, foot, and mouth disease in northern Zhejiang, China, May 2008–November 2013. BMC Infect Dis. 2014;14:251.

16. Chen KT, Chang HL, Wang ST, Cheng YT, Yang JY. Epidemiologic features of hand-foot-mouth disease and herpangina caused by enterovirus 71 in Taiwan, 1998–2005. Pediatrics. 2007;120(2):e244–e252.

17. Zou XN, Zhang XZ, Wang B, Qiu YT. Etiologic and epidemiologic analysis of hand, foot, and mouth disease in Guangzhou city: a review of 4,753 cases. Braz J Infect Dis. 2012;16(5):457–465.

18. McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75–83.

19. Ooi MH, Wong SC, Lewthwaite P, Cardosa MJ, Solomon T. Clinical features, diagnosis, and management of enterovirus 71. Lancet Neurol. 2010;9(11):1097–1105.

20. Park K, Lee B, Baek K, et al. Enteroviruses isolated from herpangina and hand-foot-and-mouth disease in Korean children. Virol J. 2012;9:205.

21. Centers for Disease Control and Prevention. Adult appropriate antibiotic use summary. http://www.cdc.gov/getsmart/community/materials-references/print-materials/hcp/adult-approp-summary.pdf. Accessed March 8, 2016.

22. Centor RM, Samlowski R. Avoiding sore throat morbidity and mortality: when is it not “just a sore throat?”. Am Fam Physician. 2011;83(1):26, 28.

23. Cooper RJ, Hoffman JR, Bartlett JG, et al.; American Academy of Family Physicians; American College of Physicians-American Society of Internal Medicine; Centers for Disease Control. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001;134(6):509–517.

24. American Academy of Pediatrics, Committee on Infectious Diseases. Red Book. 26th ed. Elk Grove Village, Ill.: American Academy of Pediatrics; 2003:578–580.

25. Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847–852.

26. Catanzaro FJ, Stetson CA, Morris AJ, et al. The role of the streptococcus in the pathogenesis of rheumatic fever. Am J Med. 1954;17(6):749–756.

27. Lean WL, Arnup S, Danchin M, Steer AC. Rapid diagnostic tests for group A streptococcal pharyngitis: a meta-analysis. Pediatrics. 2014;134(4):771–781.

28. Dajani A, Taubert K, Ferrieri P, Peter G, Shulman S. Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: a statement for health professionals. Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young, the American Heart Association. Pediatrics. 1995;96(4 pt 1):758–764.

29. Bisno AL. Diagnosing strep throat in the adult patient: do clinical criteria really suffice? Ann Intern Med. 2003;139(2):150–151.

30. Rimoin AW, Hamza HS, Vince A, et al. Evaluation of the WHO clinical decision rule for streptococcal pharyngitis. Arch Dis Child. 2005;90(10):1066–1070.

31. Cleveland Clinic. Diseases and conditions: strep throat. http://my.clevelandclinic.org/health/diseases_conditions/hic_Group_A_Streptococcal_Infections/hic_strep_throat. Accessed June 8, 2015.

32. van Driel ML, De Sutter AI, Keber N, Habraken H, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2013;(4):CD004406.

33. Altamimi S, Khalil A, Khalaiwi KA, Milner RA, Pusic MV, Othman MA. Short-term late-generation antibiotics versus longer term penicillin for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. 2012;(8):CD004872.

34. Tanz RR, Shulman ST, Shortridge VD, et al.; North American Streptococcal Pharyngitis Surveillance Group. Community-based surveillance in the United States of macrolide-resistant pediatric pharyngeal group A streptococci during 3 respiratory disease seasons. Clin Infect Dis. 2004;39(12):1794–1801.

35. Martin JM, Green M, Barbadora KA, Wald ER. Erythromycin-resistant group A streptococci in schoolchildren in Pittsburgh. N Engl J Med. 2002;346(16):1200–1206.

36. Lennon DR, Farrell E, Martin DR, Stewart JM. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child. 2008;93(6):474–478.

37. Wing A, Villa-Roel C, Yeh B, Eskin B, Buckingham J, Rowe BH. Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature. Acad Emerg Med. 2010;17(5):476–483.

38. McNally D, Simpson M, Morris C, Shephard A, Goulder M. Rapid relief of acute sore throat with AMC/DCBA throat lozenges: randomised controlled trial. Int J Clin Pract. 2010;64(2):194–207.

39. U.S. Food and Drug Administration. Benzocaine topical products: sprays, gels and liquids—risk of methemoglobinemia. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm250264.htm. Accessed September 19, 2014.

40. Huang Y, Wu T, Zeng L, Li S. Chinese medicinal herbs for sore throat. Cochrane Database Syst Rev. 2012;(3):CD004877.

41. Gehanno P, Dreiser RL, Ionescu E, Gold M, Liu JM. Lowest effective single dose of diclofenac for antipyretic and analgesic effects in acute febrile sore throat. Clin Drug Investig. 2003;23(4):263–271.

42. Baugh RF, Archer SM, Mitchell RB, et al.; American Academy of Otolaryngology–Head and Neck Surgery Foundation. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(1 suppl):S1–S30.

43. Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014;(11):CD001802.

44. Vincent MT, Celestin N, Hussain AN. Pharyngitis. Am Fam Physician. 2004;69(6):1465–1470.

45. Hayes CS, Williamson H Jr. Management of group A beta-hemolytic streptococcal pharyngitis [published correction appears in Am Fam Physician. 2002;65(7):1282]. Am Fam Physician. 2001;63(8):1557–1564.



 

Copyright © 2016 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 15, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article