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Group A Streptococcal (GAS) Pharyngitis | Part 1

Andi Marmor, MD and Solomon Behar, MD
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20:57

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Andi and Sol review clinical features, complications, and latest treatment options of strep pharyngitis.

  • GAS as a cause of pharyngitis is most commonly observed in children 5–15 years of age.

  • Diagnostic studies for GAS pharyngitis are not recommended for children under 3  because acute rheumatic fever is rare in children <3 years old and the incidence of strep pharyngitis and the classic presentation of strep pharyngitis are uncommon in this age group.

 

Ed’s note: the IDSA says in this situation you can consider testing a 3 year old. If a child is <3 years of age and there is household contact with a school-aged sibling with documented streptococcal pharyngitis, then it is reasonable to consider testing the child if they are symptomatic.

 

  • Strep pharyngitis can lead to nonsuppurative post-infectious disorders such as  acute rheumatic fever and poststreptococcal glomerulonephritis as well as suppurative complications like peritonsillar abscess, otitis media, bacteremia as in addition to meningitis. 

  • Antimicrobial therapy is important for the prevention of acute rheumatic fever and for the prevention of suppurative complications. Treatment of pharyngitis does not affect the development of poststreptococcal glomerulonephritis. 

  • There is a lot of  overlap between the signs and symptoms of strep and non-strep (usually viral) pharyngitis. Testing for GAS should be considered in individuals that have evidence of pharyngitis (erythema or exudate) and absence of URI symptoms such as conjunctivitis, cough, and hoarseness. The Centor criteria is used to decide when to test for strep and not when to treat.  

    • The Centor criteria consists of the following 1) absence of cough 2) tonsillar exudate 3) history of fever and 4) tender anterior cervical adenopathy. 

  • Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed  in individuals that meet the Centor criteria because clinical features alone do not reliably discriminate between GAS and viral pharyngitis.

  • RADTs currently available are highly specific (approximately 95%) and so treatment is recommended in the setting of a positive result. In children and adolescents, negative RADTs should be backed up by a throat culture .

  • Chronic pharyngeal carriers have GAS present in the pharynx but they do not have evidence of an active immunologic response to the organism. Individuals who are  chronic GAS carriers do not ordinarily require further antibiotics. Carriers are unlikely to spread the organism to their close contacts and are at very low risk for developing suppurative and nonsuppurative complications.

    • There are special situations in which eradication of carriage may be desirable, including the following: (1) during a community outbreak of acute rheumatic fever and (2) during an outbreak of GAS pharyngitis in a closed or partially closed community.

  • Acute rheumatic fever has not been described as a complication of either Group C Strep  or Group G strep pharyngitis. There is no evidence that the use of antibiotic therapy significantly decrease the duration of illness or severity of illness in patients with acute pharyngitis from either GCS or GGS.

 

Treatment options for GAS pharyngitis:

Drug, Route 

Dose or Dosage 

Duration 

For individuals without penicillin allergy 

Penicillin V, oral 

Children: 250 mg twice daily or 3 times daily; adolescents and adults: 250 mg 4 times daily or 500 mg twice daily 

10d

Amoxicillin, oral 

50 mg/kg once daily (max = 1000 mg); alternate: 25 mg/kg (max = 500 mg) twice daily 

10d

Benzathine penicillin G, intramuscular 

<27 kg: 600 000 U; ≥27 kg: 1 200 000 U 

1dose

For individuals with penicillin allergy 

Cephalexin, oral

20 mg/kg/dose twice daily (max = 500 mg/dose) 

10d

Clindamycin, oral 

7 mg/kg/dose 3 times daily (max = 300 mg/dose) 

10d

Azithromycin, oral

12 mg/kg once daily (max = 500 mg) then 6mg/kd once daily for the next 4 days

5d

 

  • Resistance of GAS to macrolides is well-known and varies geographically and temporally therefore it is important to check local resistance patterns before starting a patient on this treatment option. 

  • NSAIDS like Ibuprofen are an important adjunct therapy to help with the management of pain and fever in the setting of GAS pharyngitis.  

  • Results from multiple studies demonstrate that steroids decrease the duration and severity of signs and symptoms in GAS pharyngitis in adults and children, although the actual decrease in pain duration is minimal. 

    • However, the IDSA does not recommend using corticosteroids for GAS pharyngitis. 

Fusobacterium necrophorum is the causative agent of most cases of Lemierre's syndrome, which is associated with jugular venous thrombophlebitis and the dissemination of infection by septic emboli.

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