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Streptococcal Pharyngitis: Rapid Evidence Review

Jennifer L. Hamilton, MD, PhD
Leon McCrea, II, MD, MPH

American Family Physician. 2024;109(4):343-349.

Author disclosure: No relevant financial relationships.

Group A beta-hemolytic streptococcal pharyngitis is a common infection responsible for more than 6 million office visits in the United States annually. Only 10% of adults seeking care for a sore throat have group A beta-hemolytic streptococcal pharyngitis; however, 60% or more are prescribed antibiotics. Guidelines recommend using clinical decision rules to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear, before prescribing antibiotics. Fever, tonsillar exudate, cervical lymphadenitis, and patient ages of 3 to 15 years increase clinical suspicion. A cough is more suggestive of a viral etiology. The limited history used in these decision rules is amenable to virtual visits. After a negative rapid antigen test result, a throat culture is recommended in children and adolescents. Penicillin and amoxicillin are first-line antibiotics, with a recommended course of 10 days; first-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin. There is significant resistance to azithromycin and clarithromycin in some parts of the United States. Steroids are not recommended for symptomatic treatment. Patients with worsening symptoms after appropriate antibiotic initiation or with symptoms lasting 5 days after the start of treatment should be reevaluated. Tonsillectomy is rarely recommended as a preventive measure: seven episodes of streptococcal pharyngitis in 1 year, five episodes in each of the past 2 years, or three episodes in each of the past 3 years are commonly used thresholds for considering surgery.

More than 24 million episodes of pharyngitis are diagnosed annually in the United States, with more than 6 million office visits attributable to group A beta-hemolytic streptococcal infection.1 This article provides a summary of the best available patient-oriented evidence about streptococcal pharyngitis and guideline recommendations using clinical decision rules to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear.

WHAT'S NEW ON THIS TOPIC

Streptococcal Pharyngitis
A 2021 study of patients who had telemedicine and face-to-face visits on the same day noted that patients assessed as having low-risk McIsaac scores in the telemedicine visit also had low-risk scores in face-to-face visits.
In a cohort study, the use of broad-spectrum antibiotics for children with group A beta-hemolytic streptococcal pharyngitis was not associated with a reduction in the rate of treatment failure compared with narrow-spectrum antibiotics.
Acute rheumatic fever is increasingly rare. It has an estimated incidence of 0.5 episodes per 100,000 people in the continental United States, with higher rates in the Pacific Islands. Rheumatic heart disease develops in 50% to 70% of people with rheumatic fever.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Physicians should diagnose GABHS pharyngitis using a validated clinical decision rule and, if the patient is determined to be at intermediate or high risk, rapid antigen testing should be performed.10,21 A Clinical practice guidelines supported by randomized controlled trials and meta-analyses
A throat culture is recommended for children after a negative result on rapid antigen testing for GABHS pharyngitis.2,21 C Consensus and expert opinion
Penicillin and amoxicillin are the first-line antibiotics for treating GABHS pharyngitis.2,10,21 A Consistent, good-quality patient-oriented evidence
Azithromycin should not be prescribed for GABHS pharyngitis unless the patient is allergic to beta-lactam antibiotics.2,21 C Expert opinion based on increasing resistance to azithromycin
A throat culture and sensitivity testing should be obtained if antibiotics other than beta-lactams are prescribed for GABHS pharyngitis.10,21 C Expert opinion based on increasing resistance to azithromycin, clindamycin, and others

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 https://www.aafp.org/afpsort.

JENNIFER L. HAMILTON, MD, PhD, FAAFP, is the associate dean for medical education – simulation, the family medicine pathway director, and a professor in the Department of Family, Community, and Preventive Medicine at Drexel University College of Medicine, Philadelphia, Pa.

LEON MCCREA II, MD, MPH, FAAFP, is the Deborah J. Tuttle, MD, and John P. Piper, MD, vice dean for educational affairs and an associate professor in the Department of Family, Community, and Preventive Medicine at Drexel University College of Medicine.

Address correspondence to Jennifer L. Hamilton, MD, PhD, FAAFP, Drexel University College of Medicine, 60 N. 36th Street, HSB Room 7E09, Philadelphia, PA 19104 (jlh88@drexel.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

  1. 1.Lewnard JA, King LM, Fleming-Dutra KE, et al. Incidence of pharyngitis, sinusitis, acute otitis media, and outpatient antibiotic prescribing preventable by vaccination against group A streptococcus in the United States. Clin Infect Dis. 2021;73(1):e47-e58.
  2. 2.Shulman ST, Bisno AL, Clegg HW, et al.; Infectious Diseases Society of America. 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.
  3. 3.Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997–2010. JAMA Intern Med. 2014;174(1):138-140.
  4. 4.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.
  5. 5.Kennis M, Tagawa A, Kung VM, et al. Seasonal variations and risk factors of Streptococcus pyogenes infection: a multicenter research network study. Ther Adv Infect Dis. 2022;9 : 20499361221132101.
  6. 6.Shapiro DJ, Barak-Corren Y, Neuman MI, et al. Identifying patients at lowest risk for streptococcal pharyngitis: a national validation study. J Pediatr. 2020;220:132-138.e2.
  7. 7.Nadeau N, Kimia A, Fine AM. Impact of viral symptoms on the performance of the modified Centor score to predict pediatric group A streptococcal pharyngitis. Am J Emerg Med. 2020;38(7):1322-1326.
  8. 8.Nadeau NL, Fine AM, Kimia A. Improving the prediction of streptococcal pharyngitis; time to move past exudate alone. Am J Emerg Med. 2021;45:196-201.
  9. 9.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.
  10. 10.Centers for Disease Control and Prevention. Pharyngitis (strep throat). Reviewed June 27, 2022. Accessed July 26, 2023. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html
  11. 11.O’Halloran C, Winn A. Case 3: persistent pharyngitis in a 14-year-old girl. Pediatr Rev. 2018;39(4):213.
  12. 12.Centor RM, Witherspoon JM, Dalton HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-246.
  13. 13.McIsaac WJ, White D, Tannenbaum D, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75-83.
  14. 14.Little P, Moore M, Hobbs FDR, et al.; PRISM investigators. Primary care streptococcal management study: identifying clinical variables associated with Lancefield group A beta-haemolytic streptococci and Lance-field non–group A streptococcal throat infections from two cohorts of patients presenting with an acute sore throat. BMJ Open. 2013;3(10):e003943.
  15. 15.Kalra MG, Higgins KE, Perez ED. Common questions about streptococcal pharyngitis [published correction appears in Am Fam Physician. 2017; 95(7): 414]. Am Fam Physician. 2016;94(1):24-31.
  16. 16.Seeley A, Fanshawe T, Voysey M, et al. Diagnostic accuracy of Fever-PAIN and Centor criteria for bacterial throat infection in adults with sore throat: a secondary analysis of a randomised controlled trial. BJGP Open. 2021;5(6) ): BJGPO.2021.0122.
  17. 17.Little P, Stuart B, Hobbs FDR, et al.; DESCARTE investigators. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ. 2013;347:f6867.
  18. 18.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.
  19. 19.Willis BH, Coomar D, Baragilly M. Comparison of Centor and McIsaac scores in primary care: a meta-analysis over multiple thresholds [published correction appears in Br J Gen Pract. 2020; 70(694): 230]. Br J Gen Pract. 2020;70(693):e245-e254.
  20. 20.Malley M, Driver K, Costelloe M, et al. To prescribe or not to prescribe for paediatric sore throat: a retrospective cohort study comparing clinician-led antibiotic prescriptions to FeverPAIN and Centor scoring in a tertiary paediatric emergency department and a national review of practice. Emerg Med J. 2021;38(8):613-616.
  21. 21.Kimberlin DW, Barnett ED, Lynfield R, et al. Red Book: 2021 Report of the Committee on Infectious Diseases. 32nd ed. American Academy of Pediatrics; 2021: 694–701.
  22. 22.Worrall G, Hutchinson J, Sherman G, et al. Diagnosing streptococcal sore throat in adults: randomized controlled trial of in-office aids [published correction appears in Can Fam Physician. 2007; 53(6): 1006]. Can Fam Physician. 2007;53(4):666-671.
  23. 23.Moore M. Exploring diagnostic strategies for streptococcal throat infection remotely: a feasibility study. Ann Fam Med. 2023;21(21 suppl 1):4003.
  24. 24.Miller NE, Jensen TB, Nigon LM, et al. McIsaac score for group A streptococcal infection: comparison of electronic visits versus face-to-face visits. J Telemed Telecare. 2023;29(6):492-497.
  25. 25.Falck G, Holm SE, Kjellander J, et al. The role of household contacts in the transmission of group A streptococci. Scand J Infect Dis. 1997;29(3):239-244.
  26. 26.Leis JA, Born KB, Theriault G, et al. Using antibiotics wisely for respiratory tract infection in the era of COVID-19. BMJ. 2020;371:m4125.
  27. 27.Pecina JL, Nigon LM, Penza KS, et al. Use of the McIsaac score to predict group A streptococcal pharyngitis in outpatient nurse phone triage and electronic visits compared with in-person visits: retrospective observational study. J Med Internet Res. 2021;23(12):e25899.
  28. 28.Mustafa Z, Ghaffari M. Diagnostic methods, clinical guidelines, and antibiotic treatment for group A streptococcal pharyngitis: a narrative review. Front Cell Infect Microbiol. 2020;10:563627.
  29. 29.Ganti L, Ballinger BL. How accurate is rapid antigen testing for group A streptococcus in children with pharyngitis?. Ann Emerg Med. 2018;71(4):523-524.
  30. 30.Ehrlich JE, Demopoulos BP, Daniel KR, et al. Cost-effectiveness of treatment options for prevention of rheumatic heart disease from group A streptococcal pharyngitis in a pediatric population. Prev Med. 2002;35(3):250-257.
  31. 31.Gerber JS, Ross RK, Bryan M, et al. Association of broad- vs. narrow-spectrum antibiotics with treatment failure, adverse events, and quality of life in children with acute respiratory tract infections. JAMA. 2017;318(23):2325-2336.
  32. 32.Centers for Disease Control and Prevention. Erythromycin-resistant group A Streptococcus. December 2019. Accessed June 25, 2023. https://www.cdc.gov/drugresistance/pdf/threats-report/gas-508.pdf
  33. 33.Centers for Disease Control and Prevention. 2019 AR threats report. December 2019. Accessed July 3, 2023. https://www.cdc.gov/drugresistance/Biggest-Threats.html
  34. 34.Skoog Ståhlgren G, Tyrstrup M, Edlund C, et al. Penicillin V four times daily for five days versus three times daily for 10 days in patients with pharyngotonsillitis caused by group A streptococci: randomised controlled, open label, non-inferiority study. BMJ. 2019;367:l5337.
  35. 35.Tell D, Tyrstrup M, Edlund C, et al. Clinical course of pharyngotonsillitis with group A streptococcus treated with different penicillin V strategies, divided in groups of Centor score 3 and 4: a prospective study in primary care. BMC Infect Dis. 2022;22(1):840.
  36. 36.Frost HM, Fritsche TR, Hall MC. Beta-hemolytic nongroup A streptococcal pharyngitis in children. J Pediatr. 2019;206:268-273.e1.
  37. 37.Long B, Gottlieb M. Corticosteroids for sore throat. Acad Emerg Med. 2021;28(4):470-471.
  38. 38.Johnson D, Mead R, Kennelty K, et al. Menthol cough drops: cause for concern?. J Am Board Fam Med. 2018;31(2):183-191.
  39. 39.Nguyen BK, Quraishi HA. Tonsillectomy and adenoidectomy – Pediatric Clinics of North America. Pediatr Clin North Am. 2022;69(2):247-259.
  40. 40.Paradise JL, Bluestone CD, Bachman RZ, et al. History of recurrent sore throat as an indication for tonsillectomy. Predictive limitations of histories that are undocumented. N Engl J Med. 1978;298(8):409-413.
  41. 41.Randall DA. Current indications for tonsillectomy and adenoidectomy. J Am Board Fam Med. 2020;33(6):1025-1030.
  42. 42.Burton MJ, Glasziou PP, Chong LY, et al. Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis. Cochrane Database Syst Rev. 2014(11):CD001802.
  43. 43.Morad A, Sathe NA, Francis DO, et al. Tonsillectomy versus watchful waiting for recurrent throat infection: a systematic review. Pediatrics. 2017;139(2):e20163490.
  44. 44.Tzelnick S, Hilly O, Vinker S, et al. Long-term outcomes of tonsillectomy for recurrent tonsillitis in adults. Laryngoscope. 2020;130(2):328-331.
  45. 45.Billings KR, Maddalozzo J. Complementary and integrative treatments: adenotonsillar disease. Otolaryngol Clin North Am. 2013;46(3):329-334.
  46. 46.Bereznoy VV, Riley DS, Wassmer G, et al. Efficacy of extract of Pelargonium sidoides in children with acute non–group A beta-hemolytic streptococcus tonsillopharyngitis: a randomized, double-blind, placebo-controlled trial. Altern Ther Health Med. 2003;9(5):68-79.
  47. 47.Rystedt K, Hedin K, Tyrstrup M, et al. Agreement between rapid antigen detection test and culture for group A streptococcus in patients recently treated for pharyngotonsillitis - a prospective observational study in primary care. Scand J Prim Health Care. 2023;41(1):91-97.
  48. 48.Carius BM, Koyfman A, Long B. High risk and low prevalence diseases: Lemierre’s syndrome. Am J Emerg Med. 2022;61:98-104.
  49. 49.Tal R, Hamad Saied M, Zidani R, et al. Rheumatic fever in a developed country - is it still relevant? A retrospective, 25 years follow-up. Pediatr Rheumatol Online J. 2022;20(1):20.
  50. 50.Centers for Disease Control and Prevention. Acute rheumatic fever. Reviewed June 27, 2022. Accessed July 9, 2023. https://www.cdc.gov/groupastrep/diseases-hcp/acute-rheumatic-fever.html
  51. 51.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.
  52. 52.Hayes CS, Williamson H. 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.
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