Treatment and prevention of streptococcal pharyngitis in adults and children

●Importance of treatment – Group A Streptococcus (GAS), or Streptococcus pyogenes, is the leading bacterial cause of tonsillopharyngitis in adults and children worldwide. GAS is one of the few causes of tonsillopharyngitis or pharyngitis for which antibiotic treatment is recommended.

The goals of antibiotic therapy for GAS pharyngitis include symptom relief, preventing complications, and preventing transmission to others.

●Whom to treat – We recommend antibiotic treatment for any patient with symptomatic pharyngitis or tonsillopharyngitis who has a positive rapid antigen test or culture for GAS (Grade 1A). We generally do not treat patients who do not have microbiologic confirmation of infection or who are chronic carriers. 

●Treatment recommendations

•Preferred treatment for adults – For most adults, we treat with oral penicillin V 500 mg two to three times daily for a total of 10 days. Penicillin is the treatment of choice for GAS pharyngitis due to its efficacy, safety, narrow spectrum, and low cost.

•Preferred treatment for children – For most children, we use either oral penicillin V or amoxicillin. Amoxicillin is often preferred for young children because the taste of the amoxicillin suspension is more palatable than that of penicillin.

•Treatment for patients with a history of acute rheumatic fever – For patients with a history of acute rheumatic fever or for those who may not adhere to oral therapy, we select among oral penicillin, oral amoxicillin, or a single dose of intramuscular penicillin based on drug availability, cost, and patient values and preferences.

•Alternatives for patients who cannot tolerate penicillin – Cephalosporins, clindamycin, and macrolides are alternatives for patients who are allergic to penicillin or who cannot otherwise tolerate penicillin. Selection among these agents is based on the nature of the drug allergy or intolerance and local antibiotic resistance rates.

●Symptom resolution and return to work – Fever and sore throat typically resolve within one to three days. Most patients can return to work, school, or daycare after 12 to 24 hours of antibiotic therapy, provided they are afebrile and otherwise well.

A test of cure is usually not needed for patients who are asymptomatic at the end of a course of antibiotic therapy, except for those with a history of acute rheumatic fever or in other special circumstances.

●Management of persistent symptoms after a course of antibiotics – For patients who have persistent or recurrent symptoms after completing a course of antibiotic therapy, we repeat microbiologic testing when symptoms are compatible with GAS infection. Because chronic GAS carriage can occur after antibiotic therapy, we generally avoid testing in patients who have symptoms that are more compatible with viral pharyngitis or other etiology. 

For patients with microbiologically proven recurrent or persistent GAS pharyngitis, we repeat a 10-day course of antibiotic therapy (Grade 2C) and generally select an antibiotic that has greater beta-lactamase stability than the one used initially. Tonsillectomy is rarely indicated for such patients. 

●Prophylaxis for patients with a history of acute rheumatic fever – Antibiotic prophylaxis is used for patients with a history of acute rheumatic fever because these patients are at high risk for recurrence and for the development of chronic valvular heart disease. Antibiotic prophylaxis is not recommended for chronic carriers, except in special circumstances.