Guideline sources The following summarized guidelines for the evaluation and management of group A streptococcal pharyngitis are prepared by our editorial team based on guidelines from the American Academy of Pediatrics (AAP 2018), the British Medical Journal (BMJ 2017), the American College of Physicians (ACP/CDC 2016), the Infectious Diseases Society of America (IDSA 2012), and the European Society for Microbiology and Infectious Diseases (ESCMID 2012). 1 2 3 4 5 Pathway Calculator Calculator Group A streptococcal pharyngitis FeverPAIN score for streptococc Modified C Diagnosis and management https://web.pathway.md/diseases/recCX4WMvoSFOri2U 1/6 7/1/23, 12:05 AM Group A streptococcal pharyngitis Pathway Guidelines 1. Screening and diagnosis Indications for testing (symptomatic patients): obtain rapid antigen detection test and/or culture for group A Streptococcus in patients with symptoms suggestive of GAS pharyngitis (such as persistent fever, anterior cervical lymphadenopathy, and tonsillar/pharyngeal exudate, or other appropriate combination of symptoms). B Indications for testing (asymptomatic contacts): do not obtain routine testing in asymptomatic household contacts of patients with acute GAS pharyngitis. D 2. Classification and risk stratification Risk assessment: consider using the Centor clinical scoring system to help identify patients with a higher likelihood of group A streptococcal infection B and target antibiotic use, C recognizing that its utility in pediatric patients appears lower than in adults because of the different clinical presentation of sore throat in the first years of life. 3. Diagnostic investigations Rapid antigen detection test: As per ESCMID 2012 guidelines: Consider obtaining a rapid antigen detection test in patients with a high likelihood of streptococcal infections (3-4 Centor criteria). C Do not obtain routine rapid antigen detection test in patients with a lower likelihood of streptococcal infections (0-2 Centor criteria). D As per IDSA 2012 guidelines, obtain a rapid antigen detection test for GAS pharyngitis in most patients with symptoms of acute pharyngitis because the clinical features alone do not reliably discriminate between group A streptococcal and viral pharyngitis, except when overt viral features such as rhinorrhea, cough, oral ulcers, and/or hoarseness are present. A Show 2 more Throat culture: As per ESCMID 2012 guidelines: Do not obtain throat culture for routine diagnosis of acute sore throat to detect group A streptococci. D Do not obtain throat culture after a negative rapid antigen test for the diagnosis of group A streptococci in both pediatric and adult patients. D As per IDSA 2012 guidelines: Obtain a throat culture in pediatric and adolescent patients if the rapid antigen detection test is negative. Do not obtain throat cultures if the rapid antigen detection test is positive. A https://web.pathway.md/diseases/recCX4WMvoSFOri2U 2/6 7/1/23, 12:05 AM Group A streptococcal pharyngitis Pathway Avoid routine use of back-up throat cultures for adults with a negative rapid antigen detection test. D Anti-streptococcal antibodies: do not obtain anti-streptococcal antibody titers in the routine workup of acute pharyngitis, as they reflect past rather than current infection. D Inflammatory markers: do not obtain inflammatory markers (such as ESR, CRP, procalcitonin, anti-DNase B) routinely for the assessment of patients with acute sore throat. D 4. Medical management Antibiotic therapy: As per AAP 2018 guidelines, do not use antibiotics in patients with viral respiratory illnesses, such as viral pharyngitis. D As per ESCMID 2012 guidelines, do not initiate antibiotics to prevent the development of non- suppurative complications (rheumatic fever and acute glomerulonephritis) in low-risk patients (patients with no previous history of rheumatic fever) with acute sore throat. D Show 4 more As per IDSA 2012 guidelines: Initiate an appropriate antibiotic (penicillin or amoxicillin as the drug of choice if not allergic to these agents) at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days). A Initiate any of the following regimens in penicillin-allergic patients: a first-generation cephalosporin (if not anaphylactically sensitive) for 10 days clindamycin or clarithromycin for 10 days azithromycin for 5 days. B Analgesics: As per ESCMID 2012 guidelines, offer either ibuprofen or acetaminophen for relief of acute sore throat symptoms. A As per IDSA 2012 guidelines: Consider offering analgesic/antipyretic agents (such as acetaminophen or NSAIDs) as adjunctive therapy for the treatment of moderate-to-severe symptoms or control of high fever associated with GAS pharyngitis. B Avoid using aspirin in pediatric patients with GAS pharyngitis. D Corticosteroids: As per BMJ 2017 guidelines, consider offering corticosteroids in addition to standard care in patients with sore throat. C As per ESCMID 2012 guidelines: Do not offer routine corticosteroids in conjunction with antibiotic therapy for the treatment of patients with acute sore throat. D https://web.pathway.md/diseases/recCX4WMvoSFOri2U 3/6 7/1/23, 12:05 AM Group A streptococcal pharyngitis Pathway Consider offering corticosteroids in adult patients with more severe presentations (such as 3-4 Centor criteria). B As per IDSA 2012 guidelines, do not offer corticosteroids as adjunctive therapy in patients with GAS pharyngitis. D Zinc gluconate: do not use zinc gluconate for the treatment of patients with acute sore throat. D 5. Nonpharmacologic interventions Alternative medicine: insufficient evidence to support the use of herbal treatments and acupuncture as treatments for sore throat. I 6. Specific circumstances Management of chronic GAS carriers: Recognize that recurrent episodes of pharyngitis in patients with laboratory evidence of group A streptococcal infection may represent either: multiple episodes of bona fide recurrent streptococcal pharyngitis at close intervals, or multiple episodes of viral pharyngitis in chronic pharyngeal group A streptococcus carriers. B Do not attempt to identify nor administer antimicrobial therapy in patients with asymptomatic group A streptococcus carriage, as they are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or non-suppurative complications, such as acute rheumatic fever. D Management of asymptomatic household contacts: do not offer routine empiric treatment in asymptomatic household contacts of patients with acute streptococcal pharyngitis. D 7. Preventative measures Tonsillectomy: do not perform tonsillectomy with the sole intent of reducing the frequency of streptococcal pharyngitis. D 8. Follow-up and surveillance Post-treatment throat culture: do not obtain routine follow-up post-treatment throat cultures or rapid antigen detection tests; consider these only in special circumstances. D Clinical findings Patient demographics Symptoms https://web.pathway.md/diseases/recCX4WMvoSFOri2U 4/6 7/1/23, 12:05 AM Group A streptococcal pharyngitis Pathway Children Abdominal pain Dysphagia Past medical history Fever Headache Peritonsillar abscess Malaise Scarlet fever Nausea Upper respiratory tract infection No history of cough Lymphatic exam Odynophagia Throat pain Cervical lymphadenopathy Vomiting Lab findings Head and neck exam ESR Palatine petechiae serum CRP Pharyngeal erythema Pharyngeal exudate Microbiological findings Strawberry tongue rapid streptococcal antigen test Swollen uvula Tonsillar enlargement throat culture for group A streptococci Tonsillar exudate Integument exam Rash Sandpaper-like rash Hematological findings Likelihood Ratios Pertinent positives The following findings increase the probability of group A streptococcal pharyngitis in adults. 6 7 Finding LR+ Value Positive rapid streptococcal antigen test 83 Increased Centor score ( 2) 1 Pertinent negatives The following findings decrease the probability of group A streptococcal pharyngitis in adults. 6 7 https://web.pathway.md/diseases/recCX4WMvoSFOri2U 5/6 7/1/23, 12:05 AM Group A streptococcal pharyngitis Pathway Finding LR- Value Negative throat culture for group A streptococci References Positive EBV point-of-care test 0 0.09 (0.03-0.24) Negative rapid streptococcal antigen test 0.2 1. 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