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. 2006 Jun 6;6(2):69–78. doi: 10.1016/S1045-1870(05)80054-8

Diagnosis and treatment of group a streptococcal pharyngitis

Robert R Tanz a,b,c,*, Stanford T Shulman a,b,c
PMCID: PMC7128789  PMID: 32288448

Summary

Pharyngitis caused by the group A streptococcus requires accurate diagnosis and timely treatment to prevent acute rheumatic fever. Clinical signs and symptoms often do not distinguish pharyngitis caused by group A streptococci from pharyngitis caused by other microorganisms. Rapid antigen detection or throat culture are recommended for diagnosis except when viral signs and symptoms are prominent. Therapy with penicillin, the drug of choice, is associated with prevention of rheumatic fever, more rapid clinical improvement, and prompt loss of contagiousness. Bacteriologic treatment failure occurs despite universal sensitivity of group A streptococci to penicillin. The cause of treatment failure (and of chronic carriage) remain to be determined. Newer, more expensive antibiotics do not substantially enhance treatment success and need not be prescribed for most patients.

References

  • 1.Schappert SM. National Center for Health Statistics; Hyattsville, MD: 1992. (National Ambulatory Medical Care Survey: 1990 Summary). Advance data from vital and health statistics; no. 213. [PubMed] [Google Scholar]
  • 2.Woodwell D. National Center for Health Statistics; Hyattsville, MD: 1992. Office visits to pediatric specilists 1989. (Advance data from vital and health statistics). no. 208. [Google Scholar]
  • 3.Stevens DL, Tanner MH, Winship J. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med. 1989;321:1–7. doi: 10.1056/NEJM198907063210101. [DOI] [PubMed] [Google Scholar]
  • 4.Smith TD, Wilkinson V, Kaplan EL. Group A streptococcus-associated upper respiratory, tract infections in a day care center. Pediatrics. 1989;83:380–384. [PubMed] [Google Scholar]
  • 5.Wannamaker LW, Denny FW, Perry WD. The effect of penicillin prophylaxis on streptococcal disease rates and the carrier state. N Engl J Med. 1953;249:1–7. doi: 10.1056/NEJM195307022490101. [DOI] [PubMed] [Google Scholar]
  • 6.Randolph MF, Gerber MA, DeMeo KK. Effect of antibiotic therapy on the clinical course of streptococcal pharyngitis. J Pediatr. 1985;106:870–875. doi: 10.1016/s0022-3476(85)80228-6. [DOI] [PubMed] [Google Scholar]
  • 7.Breese BB. A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. Am J Dis Child. 1977;131:514–517. doi: 10.1001/archpedi.1977.02120180028003. [DOI] [PubMed] [Google Scholar]
  • 8.Poses RM, Cebul RD, Collins M. The accuracy of experienced physicians' probability estimates for patients with sore throats: Implications for decision making. JAMA. 1985;254:925–929. [PubMed] [Google Scholar]
  • 9.Breese BB, Disney FA. The accuracy of diagnosis of beta streptococcal infections on clinical grounds. J Pediatr. 1954;44:670–673. doi: 10.1016/s0022-3476(54)80008-4. [DOI] [PubMed] [Google Scholar]
  • 10.Gerber MA, Spadaccini LJ, Wright LL. Latex agglutination tests for rapid identification of group A streptococci direcetly from throat swabs. J Pediatr. 1984;105:702–705. doi: 10.1016/s0022-3476(84)80286-3. [DOI] [PubMed] [Google Scholar]
  • 11.Berkowitz CD, Anthony BF, Kaplan EL. Cooperative study of latex agglutination to identify group A streptococcal antigen on throat swabs in patients with acute pharyngitis. J Pediatr. 1985;107:89–92. doi: 10.1016/s0022-3476(85)80621-1. [DOI] [PubMed] [Google Scholar]
  • 12.Lieu TA, Fleisher GR, Schwartz JS. Clinical performance and effect on treatment rates of latex agglutination testing for streptococcal pharyngitis in an emergency department. Pediatr Infect Dis J. 1986;5:655–659. doi: 10.1097/00006454-198611000-00011. [DOI] [PubMed] [Google Scholar]
  • 13.Gerber MA, Randolph MF, Chanatry J. Antigen detection test for streptococcal pharyngitis: Evaluation of sensitivity with respect to true infections. J Pediatr. 1986;108:654–657. doi: 10.1016/s0022-3476(86)81036-8. [DOI] [PubMed] [Google Scholar]
  • 14.Dobkin D, Shulman ST. Evaluation of an ELISA for group A streptococcal antigen for diagnosis of pharyngitis. J Pediatr. 1987;110:566–569. doi: 10.1016/s0022-3476(87)80550-4. [DOI] [PubMed] [Google Scholar]
  • 15.Cochi SL, Fraser DW, Hightower AW. Diagnosis and treatment of streptococcal pharyngitis: Survey of U.S. practitioners. In: Shulman ST, editor. Pharyngitis: Management in an Era of Declining Rheumatic Fever. Praeger; New York, NY: 1984. pp. 73–94. [Google Scholar]
  • 16.Schwartz B, Fries S, Fitzgibbon AM. Pediatricians' diagnostic approach to pharyngitis and impact of CLIA 1988 on office diagnostic tests. JAMA. 1994;271:234–238. [PubMed] [Google Scholar]
  • 17.Tanz RR, Hofer C. A survey of U.S. pediatricians' strategies for managing group A streptococcal (GABS) pharyngitis. Abstracts of the XII Lancefield International Symposium on Streptococci and Streptococcal Diseases; St. Petersburg, Russia; 1993. (abstr L3) [Google Scholar]
  • 18.Kaplan EL, Huwe BB. The sensitivity and specificity of an agglutination test for antibodies to streptococcal extracellular antigens: A quantitative analysis and comparison of the Streptozyme test with the anti-streptolysin O and anti-deoxyribonuclease B tests. J Pediatr. 1990;96:367–373. doi: 10.1016/s0022-3476(80)80674-3. [DOI] [PubMed] [Google Scholar]
  • 19.Catanzaro FJ, Stetson CA, Morris LJ. Symposium on rheumatic fever and rheumatic heart disease: The role of the streptococcus in the pathogenesis of rheumatic feverAm J Med. 1954;17:749–756. doi: 10.1016/0002-9343(54)90219-3. [DOI] [PubMed] [Google Scholar]
  • 20.Randolph MF, Gerber MA, DeMeo KK. The effect of antibiotic therapy on the clinical course of streptococclal pharyngitis. J Pediatr. 1985;106:870–875. doi: 10.1016/s0022-3476(85)80228-6. [DOI] [PubMed] [Google Scholar]
  • 21.Krober MS, Bass JW, Michels GN. Streptococcal pharyngitis: Placebo-controlled double-blind evaluation of clinical response to penicillin therapy. JAMA. 1985;253:1271–1274. doi: 10.1001/jama.253.9.1271. [DOI] [PubMed] [Google Scholar]
  • 22.Hall CB, Breese BB. Dose penicillin make Johnny's strep throat better. Pediatr Infect Dis J. 1984;3:7–9. doi: 10.1097/00006454-198401000-00003. [DOI] [PubMed] [Google Scholar]
  • 23.Denny FW. Current problems in managing streptococcal pharyngitis. J Pediatr. 1987;111:797–806. doi: 10.1016/s0022-3476(87)80191-9. [DOI] [PubMed] [Google Scholar]
  • 24.Breese BB, Disney FA, Talpey WB. The prevention of type-specific immunity to streptococcal infections due to the therapeutic use of penicillin. Am J Dis Child. 1960;74:353–359. doi: 10.1001/archpedi.1960.04020040355007. [DOI] [PubMed] [Google Scholar]
  • 25.Pichichero ME, Disney FA, Talpey WB. Adverse and beneficial effects of immediate treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin. Pediatr Infect Dis J. 1987;6:635. doi: 10.1097/00006454-198707000-00004. [DOI] [PubMed] [Google Scholar]
  • 26.Gerber MA, Randolph MF, Demeo KK. Lack of impact of early antibiotic therapy for, streptococcal pharyngitis on recurrence rates. J Pediatr. 1990;117:853–858. doi: 10.1016/s0022-3476(05)80121-0. [DOI] [PubMed] [Google Scholar]
  • 27.Coonan KM, Kaplan EL. In vitro susceptibility of recent North American group A streptococcal isolates to eleven oral antibiotics. Pediatr Infect Dis J. 1994;13:630–635. doi: 10.1097/00006454-199407000-00009. [DOI] [PubMed] [Google Scholar]
  • 28.Gerber MA, Spadaccini LJ, Wright LL. Twice-daily penicillin in the treatment of streptococcal pharyngitis. Am J Dis Child. 1985;139:1145–1148. doi: 10.1001/archpedi.1985.02140130083035. [DOI] [PubMed] [Google Scholar]
  • 29.Breese BB, Disney FA, Talpey WB. Penicillin in streptococcal infections: Total dose and frequency of administation. Am J Dis Child. 1965;110:125–130. doi: 10.1001/archpedi.1965.02090030135003. [DOI] [PubMed] [Google Scholar]
  • 30.Gerber MA, Randolph MF, Chanatry J. Five v ten days of penicillin V therapy for streptococcal pharyngitis. Am J Dis Child. 1987;141:224–227. doi: 10.1001/archpedi.1987.04460020114043. [DOI] [PubMed] [Google Scholar]
  • 31.Schwartz RH, Wientzen RL, Jr, Pedreira F. Penicillin V for group A streptococcal pharyngitis: A randomized trial of seven v ten days therapy. JAMA. 1981;246:1790–1795. doi: 10.1001/jama.246.16.1790. [DOI] [PubMed] [Google Scholar]
  • 32.Seppala H, Nissinen A, Jarvinen H. Resistance to erythromycin in group A streptococci. N Engl J Med. 1992;326:292–297. doi: 10.1056/NEJM199201303260503. [DOI] [PubMed] [Google Scholar]
  • 33.Gastanaduy AS, Kaplan EL, Huwe BB. Failure of penicillin to eradicate group A streptococci during an outbreak of pharyngitis. Lancet. 1980;2:498–502. doi: 10.1016/s0140-6736(80)91832-2. [DOI] [PubMed] [Google Scholar]
  • 34.Tanz RR, Shulman ST, Barthel MJ. Penicillin plus rifampin eradicates pharyngeal carriage of group A streptococci. J Pediatr. 1985;106:876–880. doi: 10.1016/s0022-3476(85)80229-8. [DOI] [PubMed] [Google Scholar]
  • 35.Feldman S, Bisno AL, Lott L. Efficacy of benzathine penicillin G in group A streptococcal pharyngitis: Reevaluation. J Pediatr. 1987;110:783–787. doi: 10.1016/s0022-3476(87)80024-0. [DOI] [PubMed] [Google Scholar]
  • 36.Kaplan EL. The group A streptococcal upper respiratory tract carrier state: An enigma. J Pediatr. 1980;97:337–345. doi: 10.1016/s0022-3476(80)80178-8. [DOI] [PubMed] [Google Scholar]
  • 37.Pichichero ME, Margolis PA. A comparison of cephalosporins and penicillin in the treatment of group A beta-hemolytic streptococcal pharygnitis: A metanalysis supporting the concept of microbial copathogenicity. Pediatr Infect Dis J. 1991;10:275–281. doi: 10.1097/00006454-199104000-00002. [DOI] [PubMed] [Google Scholar]
  • 38.Pichichero ME. Cephalosporins are superior to penicillin for treatment of streptococcal tonsillopharyngitis: Is the difference worth it? Pediatr Infect Dis J. 1993;12:268–274. doi: 10.1097/00006454-199304000-00002. [DOI] [PubMed] [Google Scholar]
  • 39.Shulman ST, Gerber MA, Tanz RR. Streptococcal pharyngitis: The case for penicillin therapy. Pediatr Infect Dis J. 1994;13:1–7. [PubMed] [Google Scholar]
  • 40.Simon HJ, Sakai W. Staphylococcal antagonism to penicillin-G therapy of hemolytic streptococcal pharyngeal infection: Effect of oxacillin. Pediatrics. 1963;31:463–469. [PubMed] [Google Scholar]
  • 41.Brook I. Role of beta-lactamase-producing bacteria in the failure of penicillin to eradicate group A streptococci. Pediatr Infect Dis J. 1985;4:491–495. doi: 10.1097/00006454-198509000-00010. [DOI] [PubMed] [Google Scholar]
  • 42.Brook I. The role of beta-lactamase-producing bacteria in the persistence of streptococcal tonsillar infection. Rev Infect Dis. 1984;6:601–607. doi: 10.1093/clinids/6.5.601. [DOI] [PubMed] [Google Scholar]
  • 43.Kim KS, Kaplan EL. Association of penicillin tolerance with failure to eradicate, group A streptococci from patients with pharyngitis. J Pediatr. 1985;107:681–684. doi: 10.1016/s0022-3476(85)80392-9. [DOI] [PubMed] [Google Scholar]
  • 44.Brook I, Yocum P, Shah K. Surface v core-tonsillar aerobic and anaerobic flora in recurrent tonsillitis. JAMA. 1980;244:1696–1698. [PubMed] [Google Scholar]
  • 45.Roos K, Grahn E, Holm SE. Evaluation of beta-lactamase activity and microbial interference in treatment failures of acute streptococcal tonsillitis. Scand J Infect Dis. 1986;18:313–319. doi: 10.3109/00365548609032342. [DOI] [PubMed] [Google Scholar]
  • 46.Grahn E, Holm SE. The effect of penicillin on bacterial interference in vivo. Scand J Infect Dis. 1987;19:353–359. doi: 10.3109/00365548709018482. [DOI] [PubMed] [Google Scholar]
  • 47.Chaudary S, Bilinsky SA, Hennessy JL. Penicillin V and rifampin for the treatment of group A streptococcal pharyngitis: A randomized trial of 10 days pencillin v 10 days penicillin with rifampin during the final 4 days of therapy. J Pediatr. 1985;106:481–486. doi: 10.1016/s0022-3476(85)80687-9. [DOI] [PubMed] [Google Scholar]
  • 48.Kaplan EL, Johnson DR. Eradication of group A streptococci from the upper respiratory tract by, amoxicillin with clavulanate after oral penicillin V treatment failure. J Pediatr. 1988;113:400–403. doi: 10.1016/s0022-3476(88)80291-9. [DOI] [PubMed] [Google Scholar]
  • 49.Smith TD, Huskins WC, Kim KS. Efficacy of β-lactamase-resistant penicillin and influence of penicillin tolerance in eardicating streptococci from the pharynx after failure of penicillin therapy for group A streptococcal pharyngitis. J Pediatr. 1987;110:778–782. doi: 10.1016/s0022-3476(87)80023-9. [DOI] [PubMed] [Google Scholar]
  • 50.Tanz RR, Shulman ST, Sroka PA. Lack of influence of beta-lactamase-producing flora on recovery of group A streptococci after treatment of acute pharyngitis. J Pediatr. 1990;117:859–863. doi: 10.1016/s0022-3476(05)80122-2. [DOI] [PubMed] [Google Scholar]
  • 51.Stjernquist-Desatnik A, Orrling A, Schalen C. Penicillin tolerance in group A streptococci and treatment failure in streptococcal tonsillitis. Acta Otolaryngol. 1992;68–71(Suppl 492) doi: 10.3109/00016489209136813. [DOI] [PubMed] [Google Scholar]
  • 52.Ginsburg CM, McCracken GH, Crow SD. Seroepidemiology of the group A streptococcal carriage state in a private pediatric practice. Am J Dis Child. 1985;139:614–617. doi: 10.1001/archpedi.1985.02140080084039. [DOI] [PubMed] [Google Scholar]
  • 53.Tanz RR, Poncher JR, Corydon KE. Clindamycin treatment of chronic pharyngeal carriage of group A streptococci. J Pediatr. 1991;119:123–128. doi: 10.1016/s0022-3476(05)81052-2. [DOI] [PubMed] [Google Scholar]
  • 54.Roos K, Grahn E, Lind L. Treatment of recurrent tonsillitis by recolonization with alpha-streptococci. Eur J Clin Microciol Infect Dis. 1989;8:318–319. doi: 10.1007/BF01963463. [DOI] [PubMed] [Google Scholar]
  • 55.Paradise JL, Bluestone CD, Bachman RZ. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: Results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984;310:674–683. doi: 10.1056/NEJM198403153101102. [DOI] [PubMed] [Google Scholar]
  • 56.Waagner DC. Arcanobacterium haemolyticum: Biology of the organism and diseases in man. Pediatr Infect Dis J. 1991;10:933–939. [PubMed] [Google Scholar]
  • 57.WHO Expanded program of immunization: Outbreak of diphtheria, update. Wkly Epidemiol Rec. 1993;68:134–138. [PubMed] [Google Scholar]
  • 58.Lumio J, Jahkola M, Vuento R. Diphtheria after visit to Russia. Lancet. 1993;342:53–54. (letter) [PubMed] [Google Scholar]
  • 59.Komaroff AL, Aronson MD, Pass TM. Serologic evidence of chlamydial and mycoplasmal pharyngitis in adults. Science. 1983;222:927–929. doi: 10.1126/science.6415813. [DOI] [PubMed] [Google Scholar]
  • 60.Komaroff AL, Branch WT, Jr, Aronson MD. Chlamydial pharyngitis. Ann Intern Med. 1989;111:537–538. doi: 10.7326/0003-4819-111-6-537_2. [DOI] [PubMed] [Google Scholar]
  • 61.Hill HR, Caldwell GG, Wilson E, Hager G, Zimmerman RA. Epidemic of pharyngitis due to streptococci of Lancefield group G. Lancet. 1969;2(616):371–374. doi: 10.1016/s0140-6736(69)92713-5. [DOI] [PubMed] [Google Scholar]
  • 62.Group C streptococcal infections associated with eating home made cheese. New Mexico Morbid, Mortal Weekly Rept. October 7, 1983:510. [PubMed] [Google Scholar]; Group C streptococcal infections, associated with eating home made cheese. New Mexico Morbid Mortal Weekly Rept. October 7, 1983:515–516. [PubMed] [Google Scholar]
  • 63.Gerber MA, Randolph MF, Martin NJ. Community-wide outbreak of group G streptococcal pharyngitis. Pediatrics. 1991;87:598–603. [PubMed] [Google Scholar]
  • 64.Massel BF, Chute CG, Walker AM, Kurland GS. Penicillin and the marked decrease in morbidity and mortality from rheumatic fever in the United States. N Engl J Med. 1988;318:280–286. doi: 10.1056/NEJM198802043180504. [DOI] [PubMed] [Google Scholar]
  • 65.Veasy LG, Wiedmeier SE, Orsmond GS. Resurgence of acute rheumatic fever in the intermountain, area of the United States. N Engl J Med. 1987;316:421–427. doi: 10.1056/NEJM198702193160801. [DOI] [PubMed] [Google Scholar]
  • 66.Veasy LG, Tani LY, Hill HR. Persistence of acute rheumatic fever in the intermountain area of the United States. J Pediatr. 1994;124:9–16. doi: 10.1016/s0022-3476(94)70247-0. [DOI] [PubMed] [Google Scholar]
  • 67.Bisno AL. Group A streptococcal infections and acute rheumatic fever. N Engl J Med. 1991;325:783–793. doi: 10.1056/NEJM199109123251106. [DOI] [PubMed] [Google Scholar]

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