The Infectious Disease Society of America recently released its guidelines for the diagnosis and treatment of Group A Streptococcal (GAS) Pharyngitis. It’s difficult when a patient has a sore throat, but it’s a stick-to-your-guns issue for the good of your patients. And it is important in the reduction of unnecessary antibiotic use.

1. Clinical features are not reliable. A rapid strep antigen test should be performed unless the symptoms are overtly viral in nature (rhinorrhea, cough, oral ulcers, hoarseness). In children and adolescents a negative rapid test should be backed up by culture.
2. Back-up cultures are generally not necessary in adults because of the low incidence of both GAS and its complications. Individual practice may vary on this one.
3. ASO titers – don’t do.
4. Testing for GAS pharyngitis is not recommended if features point to a viral etiology, which is far more common.
5. Diagnostic testing for GAS pharyngitis is not indicated for children < 3 years old as the incidence is low and the classic presentation (pharyngitis) is uncommon in this age group. The primary reason to treat GAS pharyngitis is to prevent post-streptococcal suppurative and non-suppurative complications (e.g. rheumatic fever). The incidence of RF is very low in children < 3 yrs of age. Other risk factors may come into play here (e.g. a sibling with GAS).
6. Generally no need for a test of cure.
7. No routine testing of asymptomatic household contacts.
8. Usually 10 days of treatment – penicillin or amoxicillin.
9. If allergic to penicillin, use a first-generation cephalosporin (if not contraindicated because of PCN anaphylaxis), clindamycin, clarithromycin, or azithromycin (5 days).
10. Adjunctive treatment with analgesics/antipyretics may be useful. NO ASPIRIN FOR CHILDREN. No steroids.
11. With recurrent GAS positive infections, consider the possibility of a GAS carrier state with intercurrent viral infections.
12. Carriers rarely develop complications of GAS and are unlikely to spread GAS pharyngitis to their close contacts, so attempts to identify the carrier state are not ordinarily justified. Eradication of the carrier state is difficult. Treatment of carriers might be appropriate when there are: (a) outbreaks of RF or post-GAS glomerulonephritis or invasive GAS infections, (b) outbreaks in closed or partially closed communities, (c) when a family member has a history of RF, (d) when the patient is excessively anxious, or (e) if tonsillectomy is being considered for carriage.
13. Tosillectomy to reduce GAS pharyngitis is not recommended.

As always colleagues – wash your hands. Don’t spread bugs between your patients and don’t bring bugs home.

Marshall Kubota, MD

Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharnyngitis: 2012 Update by the Infectious Diseases Society of America. Shulman, S.T., et. al. CID, online 9/9/2012.