Diagnosis and Treatmentof Streptococcal PharyngitisBETH A. (HOBY, MD, Unn'c..-sityoflennessee College ofMediww-Chnttanooga, Clw_ttalwagl1, Thmcssee

Common signs and symptoms of streptococcnl pharyngitis include sore throat, temperature greater than lOOAoF(38°C), tonsillar exudates, and cerviull aclcnopaUl}'. Cough, coryza, and diarrhea are more common with viral phar-yngitis. Available diagno.'itic tests inc:1udethroat cultllf<'. Jnd rapid antigen detection testing. ThroaL cullure is coll:;iu-ercd the diagnostic standard, although the sensirivity oJ. nd specificity of rapid antigen detection testing have improwd~jgJllfi(.:anlly. The modified Centol' SCQ1'eC~n be llsed to help physici<H1S decide which 1-1J.Li~Jltsm:cd no lesLing, Lhroalcllltllre/nlpid ~ntjgell detection testing, or empiric antibiotic therapy, Penicillin (10 days of 01"31therapy or Olle injec-tion of intramuscular benwthine penicillin) is the treatmcnt of choice because of cost, narrow spectrum of activity,and effecliveness. Amoxicillin is eqn~lly effec6ve and more palatable. Erythromycin anJ Jlr~l-generation cephalospo-rins are options in patients with penicillin allergy. IncrcascJ group Abeta-hemolytic streptocoCCllS (GABHS) treatment failure with peni-cillin has been reported. Although current guidelines recommendfirst-gencratiuIl ccphalosporins for persons with penicillin allergy,some advocate the use of cephalosporins in "li! nonallergic patientsbCUlm<: of b<:tter GABHS eradication and effectivencs~ againstchronic GABBS caniage. Chronic GABHS colonization is commondespite appropriate use of antibiotic therapy. Chronic carriers arcat low risk of lr;J:llsmiLLingdisease or developing invasive GABHSin[{Tliolls, and there is generally no need to treat carrier:;. 'Whethertonsillectomy or adenoidectomy dec(cu:;cs the incidence of GABBSpharyngitis i~poorly understood. At this time, the benefits arc toosmall to oUlwclgh the associJted costs and surgical fish. (A.m PamPhysldun. 2009;?9(5):585-390. Copyright ~~;2009 American Acad-emy of Family Physicians.)

~ P,ltient information:A halldou! on strep thmai:,mitten by the author ofthis arlick is Jvailable~thnp:!l'Nww.a.lfp.o rg!afpI200~03 011383·sl

Ph<.i.r)'Ilgilis is diagnosed inll mil-,.' lion patients in U.S. emergency

departments and ~Jlllbul"'tory set-lin;!s MIDllJlly_' .~.j05t ellisodcs arc~ . e

viral. Gnmp A beta-hemolytic; str"eptococcus(GABHS), the most common bactcrial etiol-01:\).',account~ for 15 to 30 pew:llt of cases ofacute pharyngitis in children and.5 to 20 per-ccn Lin adults.2 Among school-aged children,the inddellc(::b of acute sore throat, ~wab-positive GABHS, Llm.lserologic)ll), C011 nrmeJGABHS infcchon arc 33, 13, and fight perlOU child-years, respectively.3 Thus, aOOlltone in fOlll- rlllkll"1:,n with lKLlte S01"ethroathas serologically couflflmu G-A8HS phar-yngitis. Fonr-ihn~e peT('('nt of filmilies with:lTl lnclex C8se of CABHS pharyngiti5 have nsecondary case,3 Late wlllter imrl early springar~ pe,!\z GAI)HS sensons. Tht mfection

is lrallSmilled via reSplratory secretiQ!l$, alJdthe incubation period is 24 to 72 hours.

Diagnosis of 5tr~ptoco((al PharyngitisCLINICAL DIAGNOSIS

Because the signs and symptoms of GABHSpharyngiti5 overlap extensively 'Nith otherinfectious causes, IIlLlking a diagnosis ba"fOsolely on clinical findings is difficult_ Inpatit:nts 'Nith de ule 1\;brile res FiIatory illness,ph\'sicians <lcCLHJtely difierenti<lk Gact,~rialfrom viral infections using only tlie Imlory,Ind physical hndillO:;C, abouL one half of theti me.'l No slllglc dement ot"the patient's his-tory or phYSIcal exammation reliably con-films or txdudes GARHS rhnryngitis_" SoreIII rua(, kver "~lithsudd-en onsd (ll;!l!lpt'fClill rf

grtater tiulllOO.1°F [_'lSOC]), rmd exposmeto ,SLnpuxoccus ,v-ithin the preceding 1IVO

11Clwnlo~d"d('Ullr lire rmC'rlr~n FQmirj rhy"cl~n Web sit" at \'.",Wi a~h'"'Qidv,Cwyri)h( I) 2ml'1 Amerrcan ACdUeJllY of Fo;J1il~;'Ily,i(iam, Fo: lh~ rfi,'or~_ nnn:O"''''.;c;olw,e <.if ~"u InOI'IICunlmer ot tll~ Wei) ,;\e. All oll,~, 'i~I!~, r~i~fYGO,CUIl;;]C[mrynGr,tS(';>il~tp,org ForC'J"'}.,-iQill'1uu\lio,,~ J1d-'r.r r"rrr.il1I'~r. r~qu"s:s.

Streptococcal Pharyngitis

Ciill/cal recomme".dJ;:;on

A 5-8, 13,37,38

el'ic!cncefating References

U5~ur clinical ucr.:isi811rull" for diagnosing GABHSpharyngitis irnpr;)ves quality nf care INhile reducingunwarranted trEatm~nt al1d 0'/2011co;t,

Peni~illinis the tr~atmeM of chOICe for GAllH5 pharyngitiS in persons who ale noL all~r9ic 10 renicillin

Tre0tmelli is 110t,yplcally indi[~led ill ,:hronic CJITil'1I01 phdyll~eJI G!'lBHS

GABH'>"group A be'G-hemolytic 5fr~ptococCll.1_

A = consistl2"!.. 0'()(,(i-'1u",",'ly p~licn!<'ri(,.'l:0d evidence: () = iilconsisrenr 0.' ,"imit·c!-qu2lit'l (lillic,'rrl-on'er;+ed ~v.'o'ence: C" consensL's, disease-Iyiempa"vic.lence, usuai pr;JClice, exµer~ (J~";'Ji(JlI, u«(,15e s2ries, For information ah.,,,t the SONT e\'I'cienre rJlin,:SyS:'e"', go fa hrrp:li',".-W'N.e:aip.orgiafpson.xmi_

weeks sLlggesLC;,I\SHS lnrection. C:ervic~1 node lymph-adenopathy ~nd phiHyngeaJ or tomillar lflfhlIlllllallOnor eXLldakS are common signs. P,datal pekchlae :mdSC<lrblinifonn ElSh <In: hlg,h II' spcClflC but U1JCOl1HHOn; a

swolkn uvu 13 is sometimt"s nOlted. Cuugh, coryza, con-junctivitIs, 8nd diJrrhe,l He more common \,vith vlr~lpharyngitis. The c1ingnostic ,l(CL-lrac), ofthcsc ,<;igns;]l1dsymptoms is listed in TIlL'ic 1:'

CLINICAL DECISION RULES

The original Centor score uses fOllJ'signs and symptomsto eSlimate the probability of acule slreplococcal phar-yngitis in adult, wilh a son;; Iluo:;!." The score was litternl()(iiiicu oy Mk1ing age and valid~L!;J in 6011:1dults :ll1dchildn:n.7•s The cuml1Lnive score determillt:~ the likeli-hood u[streptococcal ph"l'yngitis o!1d lll'.: llecd for anti-biotics (F,;gilIC J")_ Patients INith J score ot"zero or I al'C

Facto!"

A

C2, 1i3-20

3'i

at very low risk rOT ~lreptococCJ.l pharyngltis and do nol,regui re testing (Le., tlnoJ.t culLufe or rapid antigen detee-tion testing [I~I\DT]l or ~llltibiotic therapy. I-'ntients with aSC(JI"C~01'2 or:~ should be tested using RADT ol-l11ro<l1 CLd-ture; positive results warranl antibiotic therapy. PJliellb'''ith a score of4 or higher 3rt' 3t high risk (.t streptococcalpkH),ngitis, <llid emplrlC treatment may be considered.

LABORATORY DIAGNOSIS

\Nith correcL ,arnpling Jnd plJtlng tE'chniqw;:;, a slllgle-swab throaL cullure is 90 to 95 percent sensitive.I'J R/\ rnallows h:!I-earl it: I' Irt:;:-llillent,symptom improvern<:n I, amIreduu:d d15eJse spread_ RADT ~pecificity ranges from90 to 99 percent. Sensitivity depends on the COlllmer-(i,-d RADT kit used and was ilPproximuLd!' 70 percentwith older lakx ogghllin.1tion assays.ll,l" Nc\l'c enzyme-hnked immunmorhenl .1SS.lYS, optical immunoassays,

Sp':cificiry (%) Pos,'liv~iikplihood CMio Nf3gativ('? Iike/ihoJ,j mrio

o s:ftcijS90.5" Iv 0.92

--'')'b:;ence of ('Sugii

_AnLc"or cc-,YlCdln des. swollEn Q! erii~rged-Headache

:;,,:r1y~l\)i:1:"J'alatillc pdi:d'iJ<':

-Pharyn<]ea l_exudJ te~

',,5!repl:XClCcaleXpD\Ure in Pilst t,'.'ow('cbTemp"rature i-i(jo,9~~'n8_3'C) ,Tonsillar exudJrl'o;Jpr,silliir ol_phil'-YIl<]",'I.'!K,ldaie~'

51 1679

-55 to 52'

liS

7

n.to 58

36

36;t~'6S3~ 1073

50t030150;

OAi

0.81 to 2.6 0_55 lG 1

1.2

14

'(U;4

0_9D._

0.85

91

53k92'

8S

2

o 68_to'J's

J. 3

0.9-

Sfrepmcoccm

"Adapred ,·,irh P~!Il.''':,si(;,,! ~:om F.bellJvIN, Smith"Jt,MA iCOQ;2?,<J{J.J.):Z915,

Treatment of GABHS PharyngitisJUSTIFICATION rOR TREATMENT

GAEHS pharyngitis is self lillukd andf(:~olvts withill a ft>w days, even withouttre;HTIlellt_" Argumenls for antibiotic treal-ment Include nCHle symplom relief-, prevell-lwu of suppur"tive cmd llUUsupPLlrativecomplICations, ~llld leducI'd cummunicabil-ity (['llil" 2). 1,1~-1! AnLihiutics shorten symp-tom chlrulion by ahom 16 hours, the numoerTlt'"t'"ded to treal (NNT) for symptom n:lid at72 hOlll-S is fOlll !lllhus!: with po,:;itivethronl

s',vabs.1? In JUdlllllll, fClle,; of suppurative peritonsill",and rdrophafyngenl ahscc55cs flrc redu..:;cd IdptJl I1.\ilIl:lteJy one in 1,000 cases).l"l

Antibiotics also reduce the IIlcidcncc of acute r11eI1-matie fever (rehtive risk reductiun - O.28).~'1 AlthoughdH:!UmJlic heilr1 disc(lSC is a major pulillL iJt!(IlLhL;:,uc in 1011'- and midJle-income cfHlnrrir; (annual

Clinical DeCISion Rule lor Managementof Sore Throat

PaLient witli 'UI ~ lIliUdlApplystreQlococ,al'(Q,e

,c-,

(ritNi~ Points

Absen,~ of cough

Swollen and te[ld~, ,lHl~riOire'·"io.,,1 nodes

T~,1l~€ratur~;' 100A"F (38°C)

Tonsillar ~:<ud"tes or 5we lir,~

/',ge

"' to 14 yE~"15 to 44 ye2rs

,1S y~J"and old~r

Cumubl;ve swrc:

I r l- I"(Ore f. 0 Score ~ 1 Score = 2 Seok = 3

I I j IRisk of Risk oi Ri,k of r,;sk :Jf(;ABHS GABHS GA~HS GA3HSph~r}'''0Ili'' ph~, Y"9'tis pharyngili, phJ'Y">J,I,c.I lu 25% 5lJiU"'" II i<l 17% 28 to J:;%

IScore 2 4

jRiSk ofGABflSjJioclfyngitis51 to S}%y

N'J furtherlc,ti"9 or~Iltlb,u!<~,i,,\lic;11"("]

I:.....u~,."'...rP~rform throal cultu.e or RAC-T

Comldc, empirictrpatment 'NitI',all\lbioIIC,

I lPO';i;ive

INegallv,?

Ir-Jodntibiotic5 indi,:~'~d Tr~at '."ItilJntit:,iotic,

Figure 1. Modified Centm scor~ <:lfldmanagement options using clini-cal decisiDn flile. Other factors should lw CUflsiucrr:,d (e.g.. a score of 1,but recent family contact 'Nith documented streptococcal infection).(GABHS = group A beta-hemolytic streptococcus; RADT" rapid anti-gen detection testing.)

Ad~p!~d Will;;Jc·,m,~~ionilum Mc1S02( '1/J. Vihit2 D, Taw,enb;;um D. Low DE.A clinical ,(oreto redlle>2 unnecessary an/ibio(.', ll:~ in patients with ';me U"oat (MAJ. 1998;158(1):19

and CI,el[1 illlJllinescmt DNA probes J.n: '-;II)to 99 percentsellsrilve.!l.l' Hm'I'evel, newer le'il~ lWIV lw mnrr cxpen-sive, (lnd not alllt-sb ail:: 1Y1l1Ye(1 hy the Clinical LabDrd-lory lmprovement Acl \)1' 19:-:S

VV"hether negalive kADT rf'~l1lrs in childlen and aclo-lr.;ccnts requJre c011JHm:J.lory throat (nltn,.!" is contro-WTSJaI. T!Jt: Amerieiln i\ci1dcmy of' Pediatncs (AAP)

M.1rrh J, 20(.1:> • \ltll!lr,'I~ 79, ,",'Hl11ncr S II' \\'w.nnfr.org/~fp

Strepto[Q((ul Pharyngitis

reCUJlllllt:ndB that n~gJlive Ri\ DT l"e:.uhe,Ul (hildrtn be <.onJ-iuneu usmg Lhru:ll cul-tUT(' Ilnk'i,~ phy.'i'-I~ll$ can gllarantee thatkADT seJl,;lliv ily i~ ~imilar to rll::n of throat'Cl1lture in their practi(e.'~ blse-negativeRADT I-e&ults may le<lrJ 10 ITllsdiagnosls

and GABBS spread :)Ild, vt"'r-y r;[rely, 10increased suppurative and nODSuppurativecomplicJtions Other sludJes suggest thatthe Sen$ilivity of newcr optical1ll1munoas-says ,lpproachcs that of single-plate throatcullure, obv Elling the need for back-up cul-hne."';; IJt IIldllY clinical practicc:s, contir--malo IT Ihl'oClI culturi.:' is not pcrl'ormed 111chlldren :it low risk for GABHS infectiun.The pn:clpllom drop In rhi'uTIlJtic fever inthe United SUJ\es, si!',nificant costs of add i-tional le~ling <lnJ follow-up, and concernsaboLlllllappropriate autibioric USE' Jre v.llidLeasons why back-up cultures are not IOU-

tinely performed.I'Strcpt()cncc;ll .l'ltibody titers ow: nuL U3C-

hll tell diagnosing streptococcal plurYl1-gilis and arc not routinely Iecollllllcnd..:J.They may be indic~Terl tel confirm previousInfection in persons wil'h suspec·ted <lcut..:poslsLrcptococcal glomerulonephritis orrheumaric fi'vi'r They ITldy a],o hi.!lp dlstin-glli.sh .lCllt:e iJlrCcllOn from chroni,: ,:,llliel

sblus, :lIt\tuugh they arc not routinely I-ec-On11l1rnded for this purpose.

Am~,.irr'"Family PI'ysici",~ 385

inciJcn.:;c of five per IUU,UUUpersons), it has largely beencOl1trolled in industrialized nations since the 19505.2j Iti5 estimated that 3,000 In 4,000 p:llif:JlIS TTIII~1be given:.tntibiotics to prevent one case of acute rheumatic feverin developed nations.'" Rates of acme rheUillatic fevercmd n>tIopharyugca! abKc~~ hav!,; not mCTcascd fol·lowing more judicious antibiotic l-rsein children withrespir~tory infecliom:" Children with Cl\BHS phar·yngitis may return to school after 24 hours of all tibiatictherapy_"

Non-gnJup t\ h,-:I:~-hfmolytic streptococ(:i (groups Calld G) ;1150 GlI1 CJUSt JClltt phar-yngitis; these sLrains,11"1" lIsu~llI!,tYeakd with antibiotics, althollgh good clini-cal trials are lacking. FusolmCerwfn IIcaophoTlim causesendemic acute pharyngitic;, peritonsilb t- c,bsce'ss, ,mdpersistent sOl'e LhrD,tL.UnLreated Fusobw:;tenuli1 infec-tions rnay leaD to Lem ierre sYJlllrDme, ,Ill inlernali llgularvein thrombm caused by inttamm~tion Complicationsoccur whi'n septic plaqUE'S br('"k 100~(; ;"ml i::lTlhnhze.Empi.ric antibiotic therapy mll)' rednce the L;;cidence ofwmplications.

ANTIBIOTIC SELECTION

Efftctiven(:ss, spectrum of activity, safeLy, do~in~ sched-ule, cost, alld cOIIlpliance i~sm:s ;111require considcr-ation. Penicillin, penicillin cOllg(;;m;rs (ampicillin ora1l1micillinJ, dimbm)'o:.:in (Ckocin), and certain .:epha-losporim Jnd lll.lLrolicles ~ue effective agalOst GABi-IS.Bas;:d on COSt, narrow speclTllm of 8ctivity. s8fety, andr.::flicctlVcness,penicillil) is recommended by the Arneri-can Academy of family Physicians (AAFp),18 the AAP,dthe American Heart Association,'" the Infectious Dis-eases Society of Am~nca (lDSf\),' and ,he vl/orld HealthOrganizatinl1 for the tr('~tment of streptococcal phM-YllSiLi~Y Options for penicillin dosinR an:: liskd 1;1Table 3.""·1'!,lk'i \Vhen p8Ticnts 81'(' unlikely to completetll~ entire ClItJJ'~t' of antibiotics, a single Lntramuscu-LJr (!()SC of penicillin G bell<.<.tLhine (Riel! liT)L-A) is 8 noption. A preiIllxed renicillin G bCT1zathineiprocaine

386 Amcriwfl Pal1li/y P/'y,jcinl!

llII~clioH (Hicillill C-R) lesM:llb lIIJediull-:nwnaled dib-comfort_ Over the past 50 years, n() incrca~c in minimaliIlhibilurl' concentration OT re5Lstance to GABHS ha~ueen JUl,;ulllenLeu Curpl'Oi;.:illim or cephalobporins.;'

Oral amoxicillin suspension is often substituted forpelllcillin l)(:'calJScit tastes better. The illcdi(~ation isalso available as chewable tablets. live of eight trials(1966 to 2000) shmvcd gTe~ltf.rth~11~'iperctllt (~ABHSendic.ltion with the use of i\luoxi;::il1ill.19Ten days ofthef8py is sl,lIldard; common dosages are provided inTable 3.),l7-2~).8-J.!Amoxicillin taken once per day is likelyas effective as a regimen of three times per day. Gne ran-domized controlled trial (ReT) JemOllstrated uHnpa-rable symptom reJiefwith ollce-daily dosing, althOllghlike almost all studies of pharyngitis lH:alrnenL, the trialwas llot poweH:d Lo detect nonsuppurarive complic3-tions.)Q A recent stud\, of children three to l8 years of~ge shm\'ed that once-d_lily dosing of alUoxicillin 'VOl,uotinferior to twice-d~ily dosing; both regimens had failurerates of llho1112.0percent. 11 It should be noted that Ollce-daily ther,)py i~IJOL approved by the U.S. Food Jnd DrugAoministrJtion (FDA).

CUi'leuL U.S. treatment snide1ines recomn1,"noerythromycin for p8tients with pelllcilllJl <!lL:r.>;)f.G<l~-trointestin,)l side cffeds of (;rythromyon emse manyphysicians to insteM] prescllbc the FDA-apprOlreJsecond-gem:rlltion macrolidE'S nithromycin (Zith-romJ-x) and cbrithromycin (Biaxm). Azithromycinreaches higher cOlll.enrr,1I:iQJ)s in ph'Ir-Yll)!,caJ Li~~u(;and rt:4uires only fiw days of tre,lImenl Miluolideresist;lnce is J!Krt'd$in:s umong CAB}.!::! isohte5 in theUnited SLaLe:"likely b"_(\'l.\1seof .uithromycin ovo:nr,c.'"RepurLeu (:ARHS resistanc¢ iD certain areas nf L"lH'United Stales and Canada ~ppmJc,hes 8 to 9 percent JJ

MosL guiddincs l'ccommend reserving t:ryllEolll,'Cinfor patients who are allergic Lopemcillin.

Firsl-gcnerMion or:,] ceph,dosp',Jrill~ <In: n::(;Uill-mended for t'.rlil'IlLs with pemcillm allergy who donot hal/I; lIumcdiate-type hypersen~itivity to bela-L1Ct,1lD cmtibioLlcs. BacknologlC f~ihHe rate,; torpenicillin-tl'edll:'cl GABBS pharyngitis increased fromabout' 10 percent III the J970s to more than 30 percentin the past decaJe,'~ Several studies suggest that cepha-losporins are more efff'ctiw against GABHS than peni-cillin. Hlgh12r rate~ of GADHS eradicltion Clnd shortercou r~;ef;of ther-upr Lhat arc possible with ceplla 1.x;purillsIIFty lll' lleneficial. One meta-anJly~I., nl'j5 11-1<1]s COUl-

varin:; V~~fI{)lhc_ephnlosporins against penicillin noted,~lgllilintn lI)imore bacterioloslC and din 1[<11[<1res in thecephalosponn group (NNT = 13) ,; However, the poorquaLity of mclllded stndie.'l limited these fiJlJi11t:~, clUJ

viww,uafp.org/afp V",umr 79, NW'1htr S * ,vIr",,;!, J, 1009

Strpptorcrral PhAryngitis

urugi)!Jr.niOI)8fthfiijbii

""T.~'~1¢~,:Ah_ijpi9tI~_optl~:h~f4.i~K~~~-:PJ,-,~rYI_1~ iri'~~_n •••• _ ....... _ ... __ - "'".,',., " __ "",,":," ..... __ .... _

-Prim<lry t~,~:::,:.:,,:t{'''m''::":;~,~~by-P-e!;iLlli'l',"

brancil1oJDi~gc_ri;'vailab!e:i!i the:-Ur.it~d Slates}

--time, per

PFnlcillill (broad"pectrurn)

Or~1

500 mg t.wo .limes ~e:- day-

Childr"r, (mild to) madera;:e GI~BHSphoryngiti,}12_25 m9 per kg twe limes :J2r clc/

f<l

10 mg per kg 1hre2 times per d"yCnildren (severe GJl.BHS ?:laryngiti;;)'

22.5 m9 pCI' kg two li",~,; P"" dJy

"13,3 ITig per kg th,-ee times per G~y

"750 'ng (n(]l FDA "ppro~ed) once per d~ytAduilS (mild tll fnoder-ate GA[iHS pharYrJgitis)_

250 mg three limps per dey

"soa mg two li(,-,ro<,PC" dcly

Adults i58',8re CADI'IS pharyngiti.\)' 875 ~",gh"iC j"ncs PCI d~y

Penibllin Gbenzat'lir,e"n{Gic'iiiili

:- Pe,nidlir-(::- ::;.ci..x}ii5ij'ililS~--

Treatment fOI" patients with f'f"nicillin allergy (rec",nn",nued by ClIrrent gu idelines)Erythrnmvcin M~crolicl~ O,al Children: 30 til 50 mel p.,,, klJ pel" dely in 1','/0

,'thyhjwn~ie tD f'JUf divided Go,esl\clullS 50 1m]µe, k,l µer day ill three tc bur

di\fldcd duor,:;

1:J deyo

C'o'lcdrD/ii (Duricef; Drar,jn[lloIl9~' a'_'0ikbl~-inthe Unilee Siates)

Cer,halosporin(firs'( genEration)

Children: 30 mg pEr kg per d?y inlwooi'Jid2d doses

eral 10 days

Adults: 1 9 olle -::0t'NO tim'!5 per (let!

-'wi"

h''''roe,o, ''-omw'e'''c', 2 -Americrw Family PI!piril111 387

Streptococcal Pharyngitis

rewlls rn~r ue hkewed ly~o,;dLlbe o.:.ephalvsponns morEeffeclively erJdicJle GABI-IS cMrlage lhan penicilLi.ndoes. Although ccphalosporins arc cf£~ctiv,~, the shiftHnviH!.1('xrrn"iv(', hroild-"pectrum second- and third-generation [ephJ.lo~;porin usc is increasing. \,\-'hether("(:'phalosporins \\/ill replace penioUin 8S primM)'GABHS therapy remains to be seen.

Guidelines for TreatmentAlthougll CABHS pharyngitis 1, common, the dealapproach to management remains a matter of debate.Nlunnous praclic(:' guidelines, clinical Lrials, ~md CDslJnJlyses give diyerg~nt opil'.ions. U.S. guidelines differin whether they recommend using clinical predictionmodels versus diagnostic testing (Table 4). Several inter-!1Jtionctl guidelines recommend not testing for or treat-ing GABHS pharyngiLi~ (.)l<Ill."

Th" AAFP, Lht:/l., m(;:ric:m Colkgt: ofrhYSlCl.1nS (i,en,;t.nOthe Centers for DiseJ.';e Control Jl1d Prevention l"tC-

omm('ncl using ,1 clinical pn:diclion model to managesuspecled CABHS ph:lryngitis.1i Guidelines from thelDSA, conversely, state that cli.nical diagnosis ofGABHSph;nyngitis CGlll10t be made wilh certainty.. c\'en byt::\'p~Ti.~Jlu~\1pb)'~.i.C1dn~,and that diagnostic: testing isr"lol{uircJ." \'\'herelS ["he: CenWr ~lgori.thm effectivelyidentifies ]O\\;-,'is],:patients ill whom 1esting is llHnec-f'SS;] Iy, th..., IDSA 1~ COclCcrueJ llbuul its relatively IOV'l

positive pledictiye value with lllgher scores (a.pproXl-matdy 50 percent) and the risk of oyertreatment.J6The ..I\C1' gl.li(kline3 Attempt to prevent in8ppropri<1teantibiotic use while avoiding unnecessary testing. Dif-ferences in gui.delines are best explained by whetheremphasis is plclCedon Jvoicling inappropriJte antibioticuse or on relieving acute GABHS pharyngitis symp-toms. Several u.s. guidelines recommend confirmatorythroallultu[c for l1cgalivl:RADT II1 chilJn:n aEd ado-lescents. !,lU) ThIS approach is 1(l() percent sensitive and99 to 100 percent specific for diagnosing GABHS phar-yngilis in chlJdren.37 However, because of Lillproved1\AD'1' sensitivity, the IDSA and ACP recently om.i.ttedthis rrcommencl:ltion Coradlllts. A slmilar recommen-dation to omit confirmatory throat cultLlre after nega-tive RADT is lihly for children.

Management of Recurrent GABHS PharyngitisRi\DT is effecLive fOJ Ji<lgno~in3 Ecurn:nt GABHSmfection. In patients treaT.ed \vithin the prec~dl11g26 (bys, RADT hJ.s similar specificily and higher sell-sitivity th811 111 patients wil;hout previolls streptococ-cal infection (0.91 verSllS 0.70, respectively; P < .001)."RecurrelKe of Gf\BHS pl1alynglu~ wi.thin one L10nthmay be trea.led using Lhe:antibiotic., listed in Tobh :-;Y"'20.23-3-1 IntramuS(ular penicillin G injection is an opt.ionwheJ1 OJ"JI JJ1tibiotic., wcre illLtiJ11y prtcSlTibed.

388 ."IIJ~riwflfrmriiy Physicilm "\vww,aaip,OlgJatp Voiume 79, NrwliJer S • M~ITCllJ, 20U9

Chronic Pharyngeal CarriageClnuHlI.. Fh"lyug<:dl carna.g<: 1& lh~ p~rslst~nt pres-ence of pharyngeal GABHS wll hU1l1 'Kliy<, Illft:cLiul1 urimmunciintlammatory nsponse. Patients may carryGABHS (01 one year d~spite treatment, Chronic car-riers ~re ~t little to no risk ()( imillune-mediated post-streptococcal complications because no active immuneresponse occurS.39 Risk of GABHS transmission is verylow and is not linked to invasive group A streptowccal(GAS) infections. Unproven therapies such a~long-lnmantibIOtic usc, treatmE'11t of pets, and exclusion fromschool and other activities have proved jneffective andare best avoided.)O Carriage of one GABl-{Sserotype Joesnot preclude infection by another; therefore, throat cul-tme or RADT is appropriilte wllen GA BHS pharyngitisis suspected. Testing is unnecessary if clinical symptomssuggest viral upper respiratory infection.

Antibiotic treatment may be appropri'lte III the fol-lowing persons or situations: rCCurr(~nl GABBS infec-tion ·within a family; personal history of or dose contactwith someone ,vho h8S had acute rheumatic fever oracute poststreptococcal glomerulonephritis; closecontact willi sorn~OIJ(: whu has GAS inkClion: com-munity outiJre,lk of acute rheumiittC fever, poststrcpto-COCCJl glomerulonephritis, 01· invasive GAS infection;health care workers or paticEb i.n hospitals, chroniccalc facilil·ies, or nur·SUlg homes; L-Imilies who CHl110tbe reassured, clild children ~t nsk of tonsillectomy forrepeated GABHS ph'Lryngitis.·<9Small RCTs suggest that

intramuscular benzaLiu nt: pen lulll [1 comblncd wllllfom days of or,d rifampin (Rifadin) or <l lO-day courseof oral dindamyci.n effectively eradicates the carrierstate.'" Oral din<iJ.llIycl11, J.lilitromycin, ,Hid cephalo-sporins ~re.~lso efftctivt'.

TonsillectomyThe effect of tonsillectomy on decreasing risk tor chronicor recurrent tousillitis is poorly Ilildentood. One trial inchildren showed that the frequency of recurrent tomil-litis decre<1.~eciin the tOJ)silJectomyiadenoiclectomy andcontrol groups.'o The surgical group had onc fewer epi-sode of severe GABHS pharyngitis annually; the authorsconcluded that this small potential beneflL did not justifythe risks or cost of ~urgery. A met~-analysjs of childrenand <ldLlltswith chronic pharyngitis comparing tonsil-lectomy ·with lloluurgicul lrc:alrncill \·\iJS inconclusive"AnuLher It'Lwspectivt' study based on data from theR\,cheSL.oI· fl'idemlulugy P!:O)l2cl found that childrenwitll tonsils are threE' times more likely to develop sub-SeCjlk'nt CABHS pharyngitis than those \"<'-hohad under-gone tonsillectomies (odds ratio = 3.1, P < .nn I).'12

Streptococcal Pharynqjtis

The AuthorSETHIl.. CH08Y, r"m, FAAFP is a board-certified famil~ pnysici,y, and riir2[-toorof I""s~al"d alld procedural training ill the Departmentol Family rliiedicine,UiliversiiyotTennessee-Chattanooga. Sh~receiv~d hei·medical degreefmlllWest Virginia UniVelSilY School of Medicine in Mi}rqamCl'Nn, ami mlJlill~lda tamil", medicine re,idency at tne UnivEsil"/ uf TrolllleS5~~-McI1Jphi"alld~ fellowship in :ldv;onccd ','Jomen', hCJlth Jlld [)bst~tr;(s ill thr~ Uniw,J',ityof Tennessee-51. Francis Hospital, Memphis. She alse completed a 1dClitydevelopment fellowship at thE Waco (Tex.) FaculW DeveloClmentCentH

Addre~, correspondence [0 Beth .4. Choi.'y. MD. FI'../JFP, iiT FamilyPractice Center, 1100 E. 3rd St., Cilattanooga, TN 37403 (e-rr:a.'l:helh.choby@erlangerorgj. Reprints a.cenot a'iailable from [he author.

Author disclosure: llr. Choby is Jil J55is,,,llt editor of Th,c (or·2 (omentReview of F"lTlily Medicine.

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