Table 3.
Summary of analyzed guidelines
| Country years | Clinical score | Criteria for microbiological test | Criteria for antibiotic prescription | Antibiotic regimen | Treatment duration | Antibiotic regimen in case of penicillin allergy | |
|---|---|---|---|---|---|---|---|
| Rapid antigen detection test (RADT) | Cultural test | ||||||
| World Health Organization (WHO) 2022 [45] | Centor score | In countries with high incidence of ARF in case of Centor score 3–4 |
In countries with high incidence of ARF: - In case of Centor score 3–4 - In case of negative RADT and Centor score 3–4 |
In countries with medium or high risk of ARF: Centor score 3–4 |
Amoxicillin q 12 h Penicillin V q 6–8 h |
High risk for ARF: 10 d Low risk for ARF: 5 d |
Cephalexin or clarithromycin for 5 d |
| Germany 2021 [30] | McIsaac, or Centor, or FeverPAIN | If clinical score > 3 in children 3–15 years old | Not recommended |
Clinical score > 4: immediate antibiotic therapy Clinical score 3: delayed prescription of antibiotic therapy * *Redeemed by the pt n case of worsening or persisting symptoms after 3–5 days |
Penicillin V q 8 h | 5–7 d | Clarithromycin for 5 d |
| UK NICE 2018 [31] | Fever PAIN or Centor score | Not routinely recommended |
FeverPAIN 4–5 o Centor score 3–4: consider immediate antibiotic or backup prescription FeverPAIN 2–3: consider backup prescription |
Penicillin V in 2 doses | 5–10 d | Clarithromycin or erythromycin | |
| Netherlands 2014 [24] | Not mentioned | Only in case of complication | Only in case of peritonsillar infiltrate, severe disease or high risk of complication |
Penicillin V If peritonsillar infiltrate amoxicillin/clavulanate |
Not mentioned | Not mentioned | |
| Scotland SIGN 2010 [37] | Centor score | Not routinely recommended | Only in severe disease |
Penicillin V q 6 h |
10 d | Macrolides | |
| Canada CPS 2021 [41] | Centor score | Centor score > 3 | In region with high-incidence of ARF in case of negative RADT |
Positive microbiological test (RADT or culture) In high-risk population, if testing is not available: Centor score > 3 |
Penicillin V in 2–3 doses or amoxicillin q 12–24 h | 10 d | Clarithromycin or clindamycin for 10 d or azithromycin for 5 d |
| Spain 2020 [32] | FeverPAIN, McIsaac or Centor score |
Regardless clinical score: - Children older than 3 y with suggestive symptoms, in absence of viral symptoms - Clinical suspicion of ARF or APSGN - Acute pharyngitis in pts with ARF or contacts of subjects with ARF - Household contact of a patient with recent APSGN - High-incidence of iGAS infections or recent contact with an affected pt - Household contact of a pt with acute pharyngitis and repeated intrafamilial transmission - Children younger than 3 y with suggestive symptoms of GABHS pharyngitis and close contact of a pt with confirmed GABHS pharyngitis |
In case of negative RADT or if it is not available [63] | Positive microbiological test (RADT or culture) |
Penicillina V q 12 h Amoxicillina q 8–12 h |
10 d |
Cefadroxil for 10 da Josamycin for 10 d |
| Finland 2020 [33, 34] | Centor score | Centor score ≥ 3 |
In case of symptoms persistence and negative RADT Recommended in case of an outbreak to evaluate antimicrobial sensitivity |
Positive microbiological test (RADT or culture) | Penicillin V q 8 h | 10 d | |
| US ICSI 2017 [42] | Centor score |
Centor ≥ 3 and intention* to treat with antibiotics *The decision should be shared with the caregiver |
If negative RADT in children | Positive microbiological test (RADT or culture) | Penicillin V or amoxicillin | 10 days | Cephalexin or macrolides or clindamycin |
| US ACP/CDC 2016 [43] | Centor score | Centor ≥ 3 | Positive microbiological test (RADT or culture) |
Penicillin V q 6–12 h Amoxicillin q 12–24 h Penicillin G single dose |
10 days |
Cephalexin or cefadroxil Clindamycin or clarithromycin for 10 d or azithromycin for 5 d |
|
| Emilia Romagna (Italy) 2015 [36] | McIsaac | McIsaac 3–4 | Not recommended |
McIsaac 3–4 with positive RADT McIsaac 5 regardless RADT testing |
Amoxicillin q 12 h | 6 days | |
| US AAP 2013 [44] | McIsaac |
McIsaac ≥ 2 Not to be performed in children under 3 years old |
Positive microbiological test (RADT or culture) | Amoxicillin q 24 h | Not mentioned | Not mentioned | |
| US IDSA 2012 [10] | Not mentioned |
Children with suggestive symptoms Not to be performed under 3 years old or in case of viral symptoms |
In children and adolescents with negative RADT | Positive microbiological test (RADT or culture) |
Penicillin V q 6–12 h Amoxicillin q 12–24 h Penicillin G single dose |
10 days |
Cephalexin or cefadroxil Clindamycin or clarithromycin for 10 d or azithromycin for 5 d |
| Europe ESCMID 2012[38] | Centor McIsaac | Centor or McIsaac ≥ 3 | Non routinely recommended | Centor score 3–4 | Penicillin V q 8–12 h | 10 days | Not mentioned |
| Italy 2011 [29] | McIsaac | McIsaac ≥ 2 | Non routinely recommended | Positive microbiological test (RADT or culture) |
Penicillin V or amoxicillin q 8–12 h Penicillin G single dose |
10 days | Macrolides only if proven β-lactam antibiotics allergy |
| France 2011 [35] | McIsaac in adults |
In children older than 3 years with suggestive symptoms In adults with McIsaac ≥ 2 |
Non routinely recommended | Positive microbiological test | Amoxicillin q 12 h | 6 days |
Cefotiam cefpodoxime or cefuroxime-axetil Macrolides |
| US AHA 2009 [9] | Not mentioned | Clinical suspicion of GAS pharyngitis | Positive microbiological test |
Penicillin V q 8–12 h Amoxicillin q 24 h Penicillin G single dose |
10 days |
Cephalexin or cefadroxil Clindamycin or clarithromycin for 10 d or azithromycin for 5 d |
|
| Australia 2020 [39] | Not recommended in high-risk patients | Not recommended | In high-risk patients with suggestive symptoms perform a culture test only if follow-up is possible |
High risk for ARF and pharyngitis: prescribe antibiotics Low-risk of ARF: only in case of positive microbiological test |
Penicillin V q 12 h Penicillin G single dose |
10 days |
Cefalexin for 10 d Azithromycin for 5 d |
| New Zealand 2019 [40] | Not recommended in high-risk patients | Only in patients with low-risk of ARF | In high-risk patients with suggestive symptoms perform a culture test only if follow-up is possible |
High-risk pts in case of clinical suspicion of GAS pharyngitis: prescribe empiric antibiotic therapy to stop in case of negative culture test Low-risk pts: prescribe antibiotics only in case of severe symptoms or occupational risk of spreading (e.g., healthcare teachers, students) |
Penicillin V q 8–12 h Penicillin G single dose |
10 days | Roxithromycin or erythromycin for 10 d |
WHO World Health Organization, ARF acute rheumatic fever, APSGN acute post streptococcal glomerulonephritis, iGAS invasive group A streptococcal infections, q every, d days, h hours, y years, pts patients, UK United Kingdom, NICE National Institute of Care and Excellence, SIGN Scottish intercollegiate guidelines network, US United States of America, ICSI Institute for Clinical Systems Improvement, ACP America college of Physicians, CDC Centers for Disease Control and Prevention, AAP American Academy of Pediatrics, IDSA Infectious Diseases Society of America, AHA American Heart Association, ESCMID European Society of Clinical Microbiology and Infectious Diseases