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"Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America"

current
Published: Clinical Infectious Diseases ; 2012 ; 55 : 86 -102

Abstract

The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing.  

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*Every 12 to 18 months following publication, IDSA reviews its guidelines to determine whether an update is required. This guideline was last reviewed and deemed current as of 05/2015.

 

Recommendations

RECOMMENDATIONS FOR THE DIAGNOSIS OF GAS PHARYNGITIS

I. How Should the Diagnosis of GAS Pharyngitis Be Established?

Recommendations

  1. Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present. In children and adolescents, negative RADT tests should be backed up by a throat culture (strong, high). Positive RADTs do not necessitate a back-up culture because they are highly specific (strong, high).
  2. Routine use of back-up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances, because of the low incidence of GAS pharyngitis in adults and because the risk of subsequent acute rheumatic fever is generally exceptionally low in adults with acute pharyngitis (strong, moderate). Physicians who wish to ensure they are achieving maximal sensitivity in diagnosis may continue to use conventional throat culture or to back up negative RADTs with a culture.
  3. Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis as they reflect past but not current events; (strong, high).

II. Who Should Undergo Testing for GAS Pharyngitis?

Recommendations

  1. Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers; (strong, high).
  2. Diagnostic studies for GAS pharyngitis are not indicated for children <3 years old because acute rheumatic fever is rare in children <3 years old and the incidence of streptococcal pharyngitis and the classic presentation of streptococcal pharyngitis are uncommon in this age group. Selected children <3 years old who have other risk factors, such as an older sibling with GAS infection, may be considered for testing (strong, moderate).
  3. Follow-up posttreatment throat cultures or RADT are not recommended routinely but may be considered in special circumstances (strong, high).
  4. Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended (strong, moderate).

RECOMMENDATIONS FOR THE TREATMENT OF PATIENTS WITH GAS PHARYNGITIS

III. What Are the Treatment Recommendations for Patients With a Diagnosis of GAS Pharyngitis?

Recommendations

  1. Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days). Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents (strong, high).
  2. Treatment of GAS pharyngitis in penicillin-allergic individuals should include a first generation cephalosporin (for those not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days (strong, moderate).

IV. Should Adjunctive Therapy With Nonsteroidal Anti-inflammatory Drugs (NSAIDs), Acetaminophen, Aspirin, or Corticosteroids Be Given to Patients Diagnosed With GAS Pharyngitis?

Recommendation

10. Adjunctive therapy may be useful in the management of GAS pharyngitis.

i. If warranted, use of an analgesic/antipyretic agent such as acetaminophen or an NSAID for treatment of moderate to severe symptoms or control of high fever associated with GAS pharyngitis should be considered as an adjunct to an appropriate antibiotic (strong, high). ii. Aspirin should be avoided in children (strong, moderate). iii. Adjunctive therapy with a corticosteroid is not recommended (weak, moderate).

V. Is the Patient With Frequent Recurrent Episodes of Apparent GAS Pharyngitis Likely to Be a Chronic Pharyngeal Carrier of GAS?

Recommendations

  1. We recommend that clinicians caring for patients with recurrent episodes of pharyngitis associated with laboratory evidence of GAS pharyngitis consider that they may be experiencing >1 episode of bona fide streptococcal pharyngitis at close intervals, but they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections (strong, moderate).
  2. We recommend that GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications (eg, acute rheumatic fever; (strong, moderate).
  3. We do not recommend tonsillectomy solely to reduce the frequency of GAS pharyngitis (strong, high).

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