Practice Guidelines

IDSA Updates Guideline for Managing Group A Streptococcal Pharyngitis

lymphadenitis. The symptoms of strepto- Guideline source: Infectious Diseases Society of America coccal pharyngitis often overlap with those Evidence rating system used? Yes of viral pharyngitis, and the two cannot be Literature search described? Yes differentiated using clinical features alone unless overt viral features are present. Guideline developed by participants without relevant financial ties to industry? No Diagnosis Published source: Clinical Infectious Diseases, September 2012 Clinical features of group A streptococcal Available at: http://cid.oxfordjournals.org/content/early/2012/09/06/cid. pharyngitis and viral pharyngitis are listed cis629.full.pdf+html in Table 1. Diagnosis of group A streptococ- cal pharyngitis should be confirmed using a rapid antigen detection test and/or culture of Coverage of guidelines The Infectious Diseases Society of America a throat swab. from other organizations (IDSA) has updated its 2002 guideline on A positive result on rapid antigen detec- does not imply endorse- ment by AFP or the AAFP. managing group A streptococcal pharyngitis. tion testing is diagnostic for group A strep- The illness primarily occurs in children five tococcal pharyngitis. A backup culture A collection of Practice Guidelines published in AFP to 15 years of age. Patients typically present should be performed in children and ado- is available at http://www. with sudden onset of a sore throat, pain with lescents with negative test results. A backup aafp.org/afp/practguide. swallowing, and fever. Examination shows culture generally is not necessary in adults tonsillopharyngeal erythema, often with because the incidence of the illness and the risk of subsequent rheumatic fever are low in adults; however, it can be considered. Table 1. Features Suggestive of Group A Streptococcal Antistreptococcal antibody titers are not and Viral Pharyngitis recommended in the routine diagnosis of acute pharyngitis. Group A streptococcal infection Viral infection Diagnostic testing is not recommended Sudden onset of sore throat Conjunctivitis if clinical features strongly suggest a viral Age 5 to 15 years Coryza etiology (e.g., cough, rhinorrhea, hoarse- Fever Cough ness, oral ulcers). Testing is generally not Headache Diarrhea recommended in children younger than Nausea, vomiting, abdominal pain Hoarseness three years unless the child has risk factors, Tonsillopharyngeal inflammation Discrete ulcerative stomatitis such as an older sibling with the illness, Patchy tonsillopharyngeal exudates Viral exanthem Palatal petechiae because the illness is uncommon in this Anterior cervical adenitis (tender nodes) age group. Follow-up posttreatment testing Presentation in winter or early spring is not routinely recommended, but may be History of exposure to streptococcal considered. Testing of household contacts of pharyngitis patients with group A streptococcal pharyn- Scarlatiniform rash gitis is not routinely recommended.

Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical Treatment practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Patients with acute group A streptococcal Dis. 2012;55(10):e91. pharyngitis should be treated with an antibi- otic that is likely to eradicate the organism,

Downloaded338 American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2013 American AcademyVolume of Family 88, Physicians. Number For5 ◆ the September private, non 1,- 2013 commercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Practice Guidelines usually for 10 days. Penicillin or amoxicil- Patients with recurrent pharyngitis and lin is commonly recommended because of laboratory evidence of group A streptococ- its narrow spectrum of activity, few adverse cus may be chronic carriers who are having effects, and modest cost. Alternative antibi- repeated viral infections. Antibiotics are not otics for those with penicillin allergy include generally recommended in this case, but a first-generation cephalosporin, clindamy- may be considered in the following situa- cin, clarithromycin (Biaxin), or azithromycin tions: (1) during a community outbreak of (Zithromax). Table 2 summarizes antibiotic acute rheumatic fever, acute poststreptococ- regimens for patients with and without peni- cal glomerulonephritis, or invasive group A cillin allergy. streptococcal infection; (2) during an out- Adjunctive therapy with an analgesic or break of group A streptococcal pharyngitis antipyretic (e.g., acetaminophen, nonsteroi- in a closed or partially closed community; dal anti-inflammatory drugs) can be consid- (3) when the patient has a family or personal ered to treat moderate to severe symptoms history of acute rheumatic fever; (4) when or control a high fever. Aspirin should not be the patient or family has excessive anxiety used in children, and adjunctive corticoste- about group A streptococcal infections; or roids are not recommended in the treatment (5) when tonsillectomy is being considered of group A streptococcal pharyngitis. only because the patient is a chronic carrier.

Table 2. Treatment Regimens for Group A Streptococcal Infection

Recommendation strength, quality Drug Dose/dosage Duration of evidence

Patients without penicillin allergy Penicillin V, oral Children: 250 mg two or three times daily 10 days Strong, high Adolescents and adults: 250 mg four times daily or 500 mg twice daily

Amoxicillin, oral 50 mg per kg once daily (maximum = 1,000 mg) 10 days Strong, high Alternative: 25 mg per kg twice daily (maximum = 500 mg)

Penicillin G < 60 lb (27 kg): 600,000 U Single dose Strong, high benzathine, ≥ 60 lb: 1,200,000 U intramuscular

Patients with penicillin allergy Cephalexin 20 mg per kg per dose twice daily 10 days Strong, high (Keflex), oral* (maximum = 500 mg per dose)

Cefadroxil, oral* 30 mg per kg once daily (maximum = 1 g) 10 days Strong, high

Clindamycin, oral 7 mg per kg per dose three times daily 10 days Strong, moderate (maximum = 300 mg per dose)

Azithromycin 12 mg per kg once daily (maximum = 500 mg) 5 days Strong, moderate (Zithromax), oral†

Clarithromycin 7.5 mg per kg per dose twice daily 10 days Strong, moderate (Biaxin), oral† (maximum = 250 mg per dose)

*—Avoid in individuals with immediate hypersensitivity to penicillin. †—Resistance of group A streptococcus to these agents is well-known and varies geographically and temporally. Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e89.

September 1, 2013 ◆ Volume 88, Number 5 www.aafp.org/afp American Family Physician 339 Practice Guidelines Table 3. Treatment Regimens for Chronic Carriers of Group A Streptococcus

Recommendation strength, Drug Dose/dosage Duration quality of evidence

Clindamycin, oral 20 to 30 mg per kg per day in three doses 10 days Strong, high (maximum = 300 mg per dose) Penicillin and rifampin, Penicillin V: 50 mg per kg per day in four doses for 10 days Strong, high oral 10 days (maximum = 2,000 mg per day) Rifampin: 20 mg per kg per day in one dose for last four days of treatment (maximum = 600 mg per day) Amoxicillin/clavulanate 40 mg amoxicillin per kg per day in three doses 10 days Strong, moderate (Augmentin), oral (maximum = 2,000 mg amoxicillin per day) Penicillin G benzathine Penicillin G benzathine: Penicillin G benzathine: Strong, high (intramuscular) and < 60 lb (27 kg): 600,000 U; ≥ 60 lb: 1,200,000 U single dose rifampin (oral) Rifampin: 20 mg per kg per day in two doses Rifampin: four days (maximum = 600 mg per day)

Adapted with permission from Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e98.

Other antibiotic regimens have been shown to be substantially more effective than Answers to This Issue’s CME Quiz penicillin or amoxicillin alone in eliminat- Q1. C Q6. A, B, C, D ing chronic streptococcal carriage. Table 3 Q2. A, B Q7. A, B summarizes the treatment options. Q3. B, C, D Q8. A, B, C, D AMBER RANDEL, AFP Senior Associate Editor ■ Q4. D Q9. B Q5. B

340 American Family Physician www.aafp.org/afp Volume 88, Number 5 ◆ September 1, 2013