NTRODUCTION — Group A Streptococcus (GAS), also known as Streptococcus

pyogenes, is the most common cause of bacterial pharyngitis in children and adolescents.
The clinical features and diagnosis of GAS pharyngitis in children and adolescents will be
discussed here. The treatment, prevention, and complications of GAS pharyngitis and the
evaluation of acute pharyngitis in children and adults are discussed separately.

●(See "Treatment and prevention of streptococcal tonsillopharyngitis" and "Antibiotic

failure in the treatment of streptococcal tonsillopharyngitis".)
●(See "Complications of streptococcal tonsillopharyngitis".)
●(See "Evaluation of sore throat in children".)
●(See "Evaluation of acute pharyngitis in adults".)

MICROBIOLOGY — GAS is a facultative, gram-positive coccus that grows in chains. The

only known reservoirs are the skin and mucous membranes of the human host. The
pathogenic mechanisms underlying these infections are poorly understood; they are
discussed separately. (See "Group A streptococcus: Virulence factors and pathogenic
mechanisms".)

EPIDEMIOLOGY — GAS is the most common cause of bacterial pharyngitis in children

and adolescents. It accounts for 15 to 30 percent of all cases of pharyngitis in children
between the ages of 5 and 15 years [1-4].

In temperate climates, the incidence of GAS pharyngitis peaks during the winter and early
spring [5]. During these seasons, as many as 35 to 40 percent of cases of pharyngitis in
children and adolescents are caused by GAS.

GAS pharyngitis is most common in school-age children but may occur in younger
children, especially if they have contact with school-age children [5,6]. In a meta-analysis,
the pooled prevalence of GAS among children (<18 years) who presented to an outpatient
clinic or emergency department with sore throat was 37 percent (95% CI 32-43 percent)
[7]. The prevalence among children <5 years was 24 percent (95% CI 21-26 percent).

CLINICAL FEATURES

Children ≥3 years — In children ≥3 years, GAS pharyngitis typically has an abrupt onset.
Fever, headache, abdominal pain, nausea, and vomiting may accompany the sore throat,
which can lead to poor oral intake [3,8,9]. Additional features may include exudative
tonsillopharyngitis, with enlarged erythematous tonsils, enlarged tender anterior cervical
lymph nodes, palatal petechiae, inflamed uvula, and scarlatiniform rash (erythematous,
finely papular rash which characteristically starts in the groin and axilla and then spreads
to the trunk and extremities, followed by desquamation) (picture 1A-B) [3,8,10]. Symptoms
usually resolve spontaneously in three to five days. (See "Complications of streptococcal
tonsillopharyngitis", section on 'Scarlet fever'.)

No single sign or symptom reliably identifies GAS pharyngitis [3,8,10]. In a meta-analysis,

the following individual findings increased the probability of GAS pharyngitis to >50 percent
in children with sore throat but could not be used for definitive diagnosis [10]:

●Scarlatiniform rash (picture 1A-B)

●Palatal petechiae
●Tonsillar enlargement with or without exudate
●Vomiting
●Tender cervical nodes
Constellations of symptoms and epidemiologic features have been used to develop clinical
scores in an attempt to predict the likelihood that a throat culture will be positive for GAS
[11-14]. None is sufficiently sensitive and specific to eliminate the need for microbiologic
testing in children and adolescents [3,10,15,16]. However, they may be helpful in
determining a testing strategy. (See 'Choice of test' below.)

Children <3 years — Symptoms of streptococcal infections usually are atypical in children
<3 years of age [17]. Instead of a well-defined episode of pharyngitis, they may have
protracted symptoms of nasal congestion and discharge, low-grade fever (eg, <38.3°C
[101°F]), and tender anterior cervical adenopathy [18]. This GAS symptom complex is
called "streptococcosis."

Infants <1 year of age may present with fussiness, decreased appetite, and low-grade
fever. They often have older siblings or day care contacts with GAS infection.

Complications — Although most cases of GAS pharyngitis resolve without complications,

serious nonsuppurative and suppurative complications may occur. Nonsuppurative
complications of GAS pharyngitis include acute rheumatic fever, poststreptococcal
glomerulonephritis, and pediatric autoimmune neuropsychiatric disorders associated with
streptococcus (PANDAS). (See "Complications of streptococcal tonsillopharyngitis",
section on 'Nonsuppurative complications'.)

Suppurative complications of GAS pharyngitis include necrotizing fasciitis, bacteremia,

peritonsillar cellulitis or abscess, otitis media, and sinusitis. (See "Complications of
streptococcal tonsillopharyngitis", section on 'Suppurative complications'.)

DIAGNOSIS

Diagnostic criteria — The diagnosis of GAS pharyngitis is supported by a positive

microbiologic test (throat culture or rapid antigen detection test [RADT] for GAS) in a
patient with symptoms of GAS pharyngitis and absence of signs and symptoms of viral
infections (eg, coryza, conjunctivitis, cough, hoarseness, anterior stomatitis, discrete
ulcerative lesions or vesicles, diarrhea). (See 'Clinical features' above and 'Microbiologic
tests' below.)

However, between 5 and 21 percent of children between 3 and 15 years of age are
pharyngeal carriers of GAS [7,19,20]. Neither throat culture nor RADT for GAS can
differentiate patients with acute GAS pharyngitis from GAS carriage with intercurrent viral
illness [3]. Such patients may fail to respond to appropriate therapy for GAS infection.
(See "Treatment and prevention of streptococcal tonsillopharyngitis", section on
'Carriers' and "Antibiotic failure in the treatment of streptococcal tonsillopharyngitis",
section on 'Streptococcal carriage'.)

Identification of GAS carriage is discussed separately. (See "Treatment and prevention of

streptococcal tonsillopharyngitis", section on 'Recurrent infection'.)

Approach to testing — Our approach to testing for GAS pharyngitis is generally

consistent with that of the Infectious Diseases Society of America, the American Heart
Association, and American Academy of Pediatrics [3,8,21].

Importance of accurate diagnosis — GAS is the most common pharyngitis pathogen

that requires antimicrobial therapy. Depending upon the season, as many as 35 to 40
percent of cases of pharyngitis in children and adolescents are caused by GAS. Timely
treatment of GAS in children and adolescents is necessary to:
 ●Prevent suppurative complications and acute rheumatic fever (see "Complications of
streptococcal tonsillopharyngitis")
●Prevent disease transmission, particularly if the patient is a contact of someone with
a history of acute rheumatic fever (ARF) [8] (see "Acute rheumatic fever: Treatment
and prevention", section on 'Secondary prevention (antibiotic prophylaxis)')
●Reduce duration and severity of symptoms

Treatment of GAS pharyngitis is discussed separately. (See "Treatment and prevention of

streptococcal tonsillopharyngitis".)

Microbiologic confirmation of GAS in the pharynx before initiation of antibiotic therapy

helps to prevent unnecessary provision of antibiotics to children with viral pharyngitis (most
children with pharyngitis) [22]. (See 'Differential diagnosis' below.)

Whom to test — We suggest microbiologic testing for GAS in children and adolescents
with [3,8,21]:

●Evidence of acute tonsillopharyngitis (erythema, edema, and/or exudates) or

scarlatiniform rash (picture 1A-B) on physical examination and absence of signs and
symptoms of viral infections (eg, coryza, conjunctivitis, cough, hoarseness, anterior
stomatitis, discrete ulcerative lesions or vesicles, diarrhea). (See 'Viral
infections' below.)
●Exposure to an individual with GAS at home or school or a high prevalence of GAS
infections in the community and symptoms of GAS, including (see 'Clinical
features' above):
•For children ≥3 years – Pharyngitis, fever, headache, abdominal pain, enlarged
tender anterior cervical lymph nodes, palatal petechiae [3,8,9].
•For children <3 years – Prolonged nasal discharge, tender anterior cervical
adenopathy, and low-grade fever (eg, <38.3°C [101°F]), particularly if they have
exposure to contacts with GAS infection [6,17,18].
Clinical scoring systems for GAS are not sensitive or specific enough to eliminate the
need for microbiologic testing in children and adolescents with suspected GAS
[3,10,15,23].
●Suspected acute rheumatic fever or poststreptococcal glomerulonephritis.
(See "Acute rheumatic fever: Clinical manifestations and
diagnosis" and "Poststreptococcal glomerulonephritis".)

Whom not to test — We recommend not performing microbiologic testing for GAS in
children and adolescents with manifestations suggestive of viral illness (eg, coryza,
conjunctivitis, cough, hoarseness, anterior stomatitis, discrete ulcerative lesions or
vesicles, diarrhea) [3,21,24]. (See 'Viral infections' below.)

Choice of test — The diagnosis of GAS pharyngitis is supported by a positive throat

culture or RADT for GAS. (See 'Microbiologic tests' below.)

For children and adolescents in whom microbiologic testing for GAS is necessary:

●If throat culture results will be available in ≤48 hours, we suggest standard throat
culture rather than RADT. We verify a telephone number and obtain a pharmacy
phone number/contact information at the initial encounter.
Although we prefer throat culture, RADT is an alternative to throat culture for children
with a streptococcal score of ≥5 (ie, those in whom a positive result is most likely)
[12,25]; the streptococcal score gives one point for each of the following [12]:
•Age (5 to 15 years)
 •Season (late fall, winter, early spring)
•Evidence of acute pharyngitis (erythema, edema, and/or exudates) on physical
examination
•Tender, enlarged (>1 cm) anterior cervical lymph nodes
•Middle-grade fever (between 38.3 and 39.4°C [101 and 103ºF])
•Absence of usual signs and symptoms associated with viral upper respiratory
tract infections
●If throat culture results will take >48 hours or the patient/family does not have
reliable telephone follow-up, we suggest RADT rather than throat culture.

If initial testing with RADT is negative in a child or adolescent, we recommend follow-up

testing with standard throat culture because RADT may miss as many as 30 percent of
cases of GAS pharyngitis [3,21,26-28]. Confirmation of negative RADT with throat culture
is not necessary in adults. The risk of an initial episode of acute rheumatic fever in an adult
with GAS pharyngitis is extremely low, even if the pharyngitis is untreated [3]. (See 'RADT
for GAS'below and "Evaluation of acute pharyngitis in adults", section on 'Rapid antigen
detection test'.)

The strategy of initial testing with throat culture is more cost effective than initial testing
with RADT. Most children who require microbiologic testing for pharyngitis do not have
GAS pharyngitis and will have a negative RADT. Given that negative RADT in children and
adolescents must be confirmed with throat culture, if RADT is used as the initial test, the
majority of children and adolescents who are tested will require both RADT and throat
culture. Limiting RADT to children in whom it is likely to be positive and performing throat
cultures in the remainder minimizes the number of children who require both tests [25].

Specimen collection and processing — The key to optimizing detection of GAS in

clinical specimens is appropriate collection and transport of the sample [29]:

●Specimens should be obtained before initiation of antimicrobial therapy, since a

single dose of antibiotics can result in a negative culture or RADT.
●If RADT is to be performed, we suggest that the throat be swabbed with two swabs
simultaneously [28]. One is used for RADT; if RADT is positive, the second swab can
be discarded. If RADT is negative, the second swab can be used for standard culture.
(See 'Diagnosis' above.)
●Specimens should be obtained by vigorous swabbing of both tonsils (or tonsillar
fossae in patients who have undergone tonsillectomy) and the posterior pharynx. The
swab(s) should be moved into and out of the mouth without touching the tongue or
the buccal mucosa. The importance of obtaining an adequate specimen cannot be
overstated; the sensitivity of both culture and RADT correlate with inoculum size
[1,30,31].

Microbiologic tests

Throat culture — Throat culture is the reference standard for the diagnosis of acute
pharyngitis due to GAS [8,32]. When performed properly, the sensitivity of throat culture is
90 to 95 percent for GAS [3,21,33]. (See 'Specimen collection and processing' above.)

Throat culture is usually performed on 5 percent sheep blood agar [32]. After incubation for
18 to 24 hours at 35 to 37ºC, the plate is inspected for a small gray colony that gives rise
to an area of beta hemolysis. If no beta hemolytic colonies are seen after 18 to 24 hours,
the plate should be reincubated for an additional 24 hours before being interpreted as
negative [3,34]. Twenty-five to 40 percent of throat cultures that are ultimately positive for
GAS become positive after 24 hours [35].
Throat culture also can identify other bacteria that cause pharyngitis less commonly than
GAS (eg, group C and group G streptococci, Arcanobacterium haemolyticum). However,
most laboratories do not routinely identify these pathogens in throat cultures unless
specifically requested to do so.

RADT for GAS — RADT for GAS, sometimes referred to as rapid streptococcal antigen
tests (RSAT), are based upon enzyme or acid extraction of antigen from throat swabs [36-
39]. RADT results are available at the point of care in the office or emergency department
and, if positive, permit early institution of therapy for GAS pharyngitis. Early institution of
therapy enables earlier resolution of symptoms and return to school. However, early
therapy also predisposes to more frequent recurrences of GAS within 30 days [40,41].

RADT have a specificity of ≥95 percent and a sensitivity that varies between 70 and 90
percent for GAS [3,33,36-39,42-47]. In a 2016 meta-analysis of studies in which 58,244
children underwent both RADT and throat culture, the pooled sensitivity and specificity of
RADT were 85.6 percent (95% CI 83.3-87.6) and 95.4 percent (95% CI 94.5-96.2),
respectively [47]. Given the high specificity and limited sensitivity of the available tests, a
positive RADT is useful in establishing the diagnosis of GAS pharyngitis, but a negative
RADT does not rule out GAS; back-up throat culture should be performed in children and
adolescents with a negative RADT [3,21,26,27].

Molecular assays — We do not routinely use molecular assays (ie, nucleic acid
amplification tests [NAAT], polymerase chain reaction assays [PCR]) for the evaluation of
GAS pharyngitis. Additional evaluation is necessary to confirm the sensitivity and
specificity results in initial studies.

NAAT are used extensively for the diagnosis of infectious diseases [48]. Although they are
highly sensitive for GAS [49], the complexity of these tests frequently requires
performance in a laboratory setting, which increases the turn-around time for results.
However, two PCR assays for GAS pharyngitis that can be performed at the point of care
and provide results in ≤15 minutes are now available (Cobas Strep A test of the Liat
system, Alere i strep A test) [50,51]. Initial evaluation suggests that these PCR assays
have sensitivity and specificity >98 percent [51], thereby potentially eliminating the need
for follow-up throat culture in children with negative PCR results. Additional evaluation is
necessary before these tests are routinely recommended.

GAS serology — Serologic testing for GAS may be necessary to confirm previous
infection in patients who are being evaluated for acute rheumatic fever or
poststreptococcal glomerulonephritis, but it is not helpful in managing patients at the time
of clinical presentation with pharyngitis.

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of GAS pharyngitis includes

both infectious and noninfectious causes of pharyngitis. Most children and adolescents
with negative microbiologic tests for GAS have viral pharyngitis, which is a self-limited
condition and can be treated symptomatically. (See "Sore throat in children and
adolescents: Symptomatic treatment", section on 'General measures'.)

Noninfectious causes of pharyngitis usually can be differentiated from GAS with

information from the history. (See "Evaluation of sore throat in children", section on 'Other
conditions'.)

Other infectious causes of pharyngitis — Acute infectious pharyngitis in children and

adolescents is caused by a variety of agents (table 1). The frequency of these pathogens
varies according to the age of the child, season, and geographic area.
Microbiologic testing may be necessary to differentiate GAS pharyngitis from other
infectious causes of GAS that require treatment or infection control (table 1) and in
children and adolescents whose symptoms worsen or persist for more than five to seven
days (whether or not they were treated for GAS) [52]. (See "Treatment and prevention of
streptococcal tonsillopharyngitis", section on 'Follow-up'.)

Other bacterial infections — Other bacterial causes of pharyngitis that may require
treatment include:

●Group C and G streptococci – Group C and G streptococci have been reported to

cause epidemic and sporadic pharyngitis in school-age children and adults, although
there has been some controversy over their etiologic role [53-56]. Group C or G
streptococci may be identified with standard throat culture, but most laboratories do
not routinely identify them unless specifically requested to do so. Group C or group G
streptococcal pharyngitis may warrant treatment if the patient remains symptomatic
when the results of the culture are available. (See "Group C and group G
streptococcal infection", section on 'Treatment'.)
●Neisseria gonorrhoeae – N. gonorrhoeae is a relatively rare cause of pharyngitis
but may occur in patients with oral-genital contact. Most cases are asymptomatic;
when present, findings are nonspecific (eg, pharyngeal erythema, edema, or
exudate). Evaluation for gonococcal pharyngitis with a nucleic acid amplification test
(NAAT) or throat culture on media specific for N. gonorrhoeae may be warranted in
patients with risk factors (eg, unprotected oral genital contact). If N. gonorrhoeae is
detected, treatment is necessary to prevent transmission and disseminated disease.
(See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in
adults and adolescents", section on 'Patients with extragenital
symptoms' and "Treatment of uncomplicated gonococcal infections", section on
'Pharyngeal infection'.)
●Fusobacterium necrophorum – F. necrophorum causes most cases of jugular vein
suppurative thrombophlebitis (Lemierre syndrome). Lemierre syndrome
predominantly affects previously healthy adolescents and young adults. Clinical
features include high fever (>39°C [102.2°F]), rigors, respiratory symptoms, and
unilateral neck swelling or pain, findings typically absent in GAS pharyngitis. The
diagnosis and treatment of Lemierre syndrome are discussed separately.
(See "Suppurative (septic) thrombophlebitis", section on 'Jugular vein'.)
The potential roles of F. necrophorum in acute pharyngitis and of F.
necrophorum pharyngitis in the development of Lemierre syndrome are discussed
separately. (See "Evaluation of acute pharyngitis in adults", section on 'Other
bacteria'.)
●A. haemolyticum – A. haemolyticum pharyngitis occurs predominantly in
adolescents [57-59]. Clinical features overlap with those of GAS and include fever,
exudative pharyngitis, and rash on the extensor surfaces of the arms (picture 2)
[58,60]. The rash occurs in approximately one-half of patients, but in contrast with the
rash of scarlet fever, does not peel [57,58,60]. A. haemolyticum grows slowly on
sheep blood agar plates and produces a tiny zone of beta hemolysis after 48 to 72
hours. Detection is improved (larger colony size and wider zone of hemolysis) by
culture on human or rabbit blood agar [61]. In in vitro studies, A. haemolyticum was
unresponsive to penicillin; erythromycin is the drug of choice [57].
●Diphtheria – Diphtheria is uncommon in developed countries but is important to
consider in patients from endemic areas. In contrast with GAS pharyngitis, which has
acute onset, the onset of symptoms in diphtheria is usually gradual, beginning with
mild pharyngeal injection and erythema. The hallmark of diphtheria is the formation of
a tightly adhering gray membrane in the nares and throat (picture 3). This membrane
 occurs in at least one-third of patients and causes bleeding when it is dislodged.
(See "Clinical manifestations, diagnosis, and treatment of diphtheria", section on
'Respiratory diphtheria' and "Epidemiology and pathophysiology of diphtheria",
section on 'Epidemiology'.)
●Tularemia – Tularemia is an uncommon cause of pharyngitis that should be
considered in patients with pharyngitis unresponsive to penicillin. It is usually acquired
by ingestion of poorly cooked wild animal meat or contaminated water. Clinical
features of oropharyngeal tularemia include fever, painful ulcerative-exudative
pharyngitis, and cervical lymphadenitis. (See "Epidemiology, microbiology, and
pathogenesis of tularemia", section on 'Epidemiology' and "Clinical manifestations,
diagnosis, and treatment of tularemia".)
●Mycoplasma pneumoniae – M. pneumoniae can cause pharyngitis and other
respiratory tract illness in children ≥6 years. M. pneumoniae accounts for 5 to 16
percent of cases of pharyngitis; the wide range may be related to the cyclicity of M.
pneumoniae epidemics [62,63]. (See "Mycoplasma pneumoniae infection in children",
section on 'Respiratory tract disease'.)

Viral infections — Viruses are the most common cause of acute pharyngitis (table 1)
[32,64,65]. Clinical features suggestive of viral etiology include concurrent conjunctivitis,
coryza, cough, hoarseness, anterior stomatitis, discrete ulcerative lesions, viral
exanthems, and/or diarrhea [3].

Viral infections in the differential diagnosis of GAS pharyngitis in children and adolescents
that have important management or infection control implications include:

●Infectious mononucleosis – Epstein-Barr virus (EBV) and cytomegalovirus (CMV)

account for most cases of infectious mononucleosis, a clinical syndrome that
classically occurs in adolescents and is characterized by fever, severe pharyngitis
(which lasts longer than pharyngitis due to GAS), and anterior and posterior cervical
or diffuse lymphadenopathy, lymphocytosis, and increased aminotransferase levels
[66,67]. Prominent constitutional symptoms include fatigue, anorexia, and weight loss.
Examination findings may include periorbital or palpebral edema, mild hepatomegaly,
and splenomegaly. Patients who are treated with ampicillin, amoxicillin, or other
antibiotics may develop a characteristic rash (picture 4). Laboratory findings may
include increased aminotransferases and predominance of atypical lymphocytes in
the differential blood count. (See "Infectious mononucleosis in adults and
adolescents".)
Unlike adolescents, who typically present with classic symptoms, younger patients
with EBV infection may have a more subtle presentation that can make diagnosis
difficult. (See "Clinical manifestations and treatment of Epstein-Barr virus infection",
section on 'Primary infection'.)
Patients with infectious mononucleosis and splenomegaly require activity restriction to
prevent splenic rupture. (See "Infectious mononucleosis in adults and adolescents",
section on 'Return to sports'.)
●Primary human immunodeficiency virus (HIV) infection – Primary HIV infection
may cause an acute retroviral syndrome (similar to infectious mononucleosis) in
sexually active adolescents or rarely in children who have been sexually abused. The
onset of symptoms usually occurs within days to weeks after the initial exposure.
Clinical features of primary HIV infection include prominent cervical or generalized
adenopathy and persistent constitutional complaints (eg, fever, weight loss).
Laboratory features may include lymphopenia and increased aminotransferase levels.
(See "Acute and early HIV infection: Pathogenesis and epidemiology" and "Acute and
early HIV infection: Clinical manifestations and diagnosis".)
 ●Herpes simplex virus (HSV) – HSV pharyngitis should be considered in children
and adolescents with the characteristic enanthem or ulcerative lip lesion. HSV
pharyngitis in children and adolescents may respond to acyclovirtherapy.
(See "Herpetic gingivostomatitis in young children" and "Clinical manifestations and
diagnosis of herpes simplex virus type 1 infection", section on
'Diagnosis' and "Treatment of herpes simplex virus type 1 infection in
immunocompetent patients".)
●Influenza – Influenza infection is characterized by fever, cough, headache, and
myalgias that occur in seasonal epidemics. Pharyngitis caused by influenza may be
exudative. Influenza pharyngitis should be considered in children and adolescents
with fever and severe illness (pharyngitis, cough, or both in the absence of another
known cause of illness) during influenza season (regardless of influenza
immunization status [68]. Antiviral therapy is indicated for children at risk for
complications or severe disease (table 2). Laboratory confirmation should not delay
initiation of treatment. (See "Seasonal influenza in children: Clinical features and
diagnosis", section on 'Diagnosis' and "Seasonal influenza in children: Prevention and
treatment with antiviral drugs", section on 'Antiviral therapy'.)
●Enteroviruses – Enteroviruses, specifically coxsackie A viruses, cause herpangina,
which is characterized by small vesicles in the posterior pharynx. In one series of 50
children (aged 1 to 10 years) with acute pharyngitis, enterovirus polymerase chain
reaction was positive in 8 percent [69]. (See "Enterovirus and parechovirus infections:
Clinical features, laboratory diagnosis, treatment, and prevention".)
●Adenovirus – Adenovirus may manifest as pharyngitis, tonsillitis, or
pharyngoconjunctival fever. There are no distinguishing characteristics of infections
caused by adenovirus except in patients with pharyngoconjunctival fever. The
presence of exudate is variable. (See "Epidemiology and clinical manifestations of
adenovirus infection".)

When pharyngitis is part of a viral syndrome that causes nasopharyngitis, nasal

congestion and discharge may be more prominent than sore throat. These infections
generally resolve with symptomatic therapy. (See "The common cold in children:
Management and prevention", section on 'Symptomatic therapy'.)

Viruses that cause nasopharyngitis include:

●Rhinoviruses (see "Epidemiology, clinical manifestations, and pathogenesis of

rhinovirus infections", section on 'Clinical illness')
●Coronaviruses (see "Coronaviruses", section on 'Clinical manifestations')
●Respiratory syncytial virus (see "Respiratory syncytial virus infection: Clinical
features and diagnosis", section on 'Clinical manifestations')
●Parainfluenza viruses (see "Parainfluenza viruses in children", section on 'Clinical
presentation')

Noninfectious causes of pharyngitis — Noninfectious causes of sore throat include

irritation or drying of the pharynx, foreign body (eg, fish bone), chemical exposure, referred
pain from extrapharyngeal sources (eg, dental abscess, otitis media). These can usually
be differentiated from infectious pharyngitis through information from the history or
physical examination. (See "Evaluation of sore throat in children", section on 'Other
conditions'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines

from selected countries and regions around the world are provided separately.
(See "Society guideline links: Streptococcal tonsillopharyngitis".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education
materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
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patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on "patient info" and the keyword[s] of interest.)

●Basics topics (see "Patient education: Strep throat in children (The

Basics)" and "Patient education: Sore throat in children (The Basics)")
●Beyond the Basics topic (see "Patient education: Sore throat in children (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

●Group A Streptococcus (GAS) is the most common cause of bacterial pharyngitis in

children and adolescents. It accounts for 15 to 30 percent of all cases of pharyngitis in
children between the ages of 5 and 15 years. In temperate climates, the incidence of
GAS pharyngitis peaks during the winter and early spring.
(See 'Epidemiology' above.)
●GAS pharyngitis typically has an abrupt onset. Fever, headache, abdominal pain,
nausea, and vomiting may accompany the sore throat. Additional features may
include exudative pharyngitis, enlarged tender anterior cervical lymph nodes, palatal
petechiae, inflamed uvula, and scarlatiniform rash (picture 1A-B). Symptoms usually
resolve spontaneously in three to five days. (See 'Clinical features' above.)
●The diagnosis of GAS pharyngitis is supported by a positive microbiologic test
(throat culture or rapid antigen detection test [RADT] for GAS) in a patient with
symptoms of GAS pharyngitis and absence of signs and symptoms of viral infections
(eg, coryza, conjunctivitis, cough, hoarseness, anterior stomatitis, discrete ulcerative
lesions or vesicles, diarrhea). In children and adolescents, GAS pharyngitis should be
confirmed microbiologically before antimicrobial therapy is initiated. (See 'Diagnostic
criteria' above and "Treatment and prevention of streptococcal tonsillopharyngitis".)
●We suggest microbiologic testing for GAS in children and adolescents with
(see 'Whom to test' above):
•Evidence of acute pharyngitis (erythema, edema, and/or exudates) or
scarlatiniform rash (picture 1A-B) on physical examination and absence of signs
and symptoms of viral infections
•Exposure to an individual with GAS at home or school or a high prevalence of
GAS infections in the community and symptoms of GAS
•Suspected acute rheumatic fever or poststreptococcal glomerulonephritis
●For children and adolescents in whom microbiologic testing for GAS is necessary,
we suggest initial testing with a standard throat culture; if throat culture results will not
be available for more than 48 hours, we suggest RADT. (See 'Choice of test' above.)
●The differential diagnosis of GAS pharyngitis includes both infectious and
noninfectious causes. Most children and adolescents with negative microbiologic
tests for GAS have viral pharyngitis, which is a self-limited condition and can be
treated symptomatically without additional testing. Additional testing may be
necessary to differentiate GAS pharyngitis from other infectious causes of GAS that
 require treatment or infection control (table 1) and in children and adolescents whose
symptoms worsen or persist for more than five to seven days (whether or not they
were treated for GAS). (See 'Differential diagnosis' above.)

TRATAMIENTO

INTRODUCTION — Tonsillopharyngitis due to Streptococcus pyogenes, also known as

group A Streptococcus (GAS) (table 1 and table 2), presents with abrupt onset of sore
throat, tonsillar exudate, tender cervical adenopathy, and fever, followed by spontaneous
resolution within two to five days. Patients with sore throat lasting longer than one week
usually do not have GAS tonsillopharyngitis.

Issues related to treatment and prevention of group A streptococcal tonsillopharyngitis will

be reviewed here [1]. A general approach to patients with pharyngitis and the factors
responsible for antibiotic failure are discussed separately. (See "Evaluation of acute
pharyngitis in adults" and "Group A streptococcal tonsillopharyngitis in children and
adolescents: Clinical features and diagnosis" and "Antibiotic failure in the treatment of
streptococcal tonsillopharyngitis".)

GOALS OF THERAPY — Goals of antimicrobial therapy for eradication of group

A Streptococcus (GAS) from the pharynx in the setting of acute streptococcal pharyngitis
include:

●Reducing duration and severity of clinical signs and symptoms, including

suppurative complications
●Reducing incidence of nonsuppurative complications (eg, acute rheumatic fever)
●Reducing transmission to close contacts by reducing infectivity

Considerations of treatment include ease of antibiotic administration and limited expense

with as few adverse effects as possible [2-4].

Reducing clinical symptoms — Antibiotic therapy is most beneficial for hastening

resolution of symptoms if instituted within the first two days of illness [5-9]. Antibiotic
therapy is also beneficial for reducing suppurative complications (such as peritonsillar
abscess, cervical lymphadenitis, and mastoiditis), although the severity of signs and
symptoms of GAS pharyngitis does not predict the likelihood of complications [10].
Additional issues related to antibiotic therapy for reducing clinical symptoms are discussed
further below. (See 'Timing of therapy' below.)

Reducing nonsuppurative complications — Antibiotic therapy is primarily helpful for

reducing the incidence of acute rheumatic fever as a nonsuppurative complication of GAS
pharyngitis. The role of antibiotic therapy in decreasing the nonsuppurative complications
of glomerulonephritis and pediatric autoimmune neuropsychiatric disorder associated with
group A streptococci (PANDAS) syndrome is not clear [11].

Acute rheumatic fever — Although symptoms of GAS pharyngitis resolve without

antibiotic therapy, persistence of the organism in the upper respiratory tract elicits an
immune response that can set the stage for subsequent risk of acute rheumatic fever
(ARF) if the strain is rheumatogenic and the host is genetically predisposed. (See "Acute
rheumatic fever: Epidemiology and pathogenesis" and "Acute rheumatic fever: Clinical
manifestations and diagnosis".)

The efficacy of penicillin for primary prevention of ARF was established in the early 1950s
when military recruits with GAS tonsillopharyngitis received injectable penicillin G mixed in
peanut oil or sesame oil with 2% aluminum monostearate [12,13]. GAS eradication and
ARF primary prevention were optimized with injection schedules that provided at least 9 to
11 days of penicillin.

Subsequently, evaluation of GAS tonsillopharyngitis therapies has been based upon GAS
eradication from the upper respiratory tract; it is assumed that such eradication is an
adequate surrogate marker for efficacy in primary prevention of rheumatic fever. Antibiotic
therapy can be helpful for prevention of rheumatic fever if initiated up to nine days
following onset of symptoms [12].

Glomerulonephritis — Children younger than seven years of age appear to be at

greatest risk of poststreptococcal glomerulonephritis. Although antibiotic therapy has
efficacy for primary prevention of acute rheumatic fever, the role of antibiotics in the setting
of GAS tonsillopharyngitis for prevention of poststreptococcal glomerulonephritis is not
certain. (See "Differential diagnosis and evaluation of glomerular disease", section on
'Hematuria following upper respiratory infection'.)

PANDAS syndrome — Pediatric autoimmune neuropsychiatric disorder associated with

group A streptococci is discussed separately. It is not clear whether antibiotic therapy for
GAS pharyngitis reduces the incidence of this syndrome. (See "Complications of
streptococcal tonsillopharyngitis", section on 'PANDAS syndrome'.)

Reducing transmission — The rate of GAS transmission from an infectious case to close
contacts (such as a family or school setting) is approximately 35 percent. Antibiotic
treatment does have a role for preventing transmission of GAS. In one study including 47
children with pharyngitis and positive throat culture for GAS, subsequent throat culture
after 24 hours of treatment with penicillin was negative in about 80 percent of cases [14].
In another study including 111 children with positive rapid antigen detection test (RADT)
treated with amoxicillin (50 mg/kg) by 5:00 pm on day 1, negative follow-up RADT the
following morning was observed in 91 percent of patients [15].

Data on the duration of contagion for alternative antibiotics are not available. In untreated
patients, GAS is eliminated from the upper respiratory tract by host immune factors in 50
percent of cases at one month following acute infection [16].

Additional issues related to antibiotic therapy for reducing transmission are discussed
further below. (See 'Follow-up' below.)

TREATMENT — Antimicrobial therapy is warranted for patients with symptomatic

pharyngitis if the presence of group A streptococci (GAS) in the pharynx is confirmed by
culture or rapid antigen detection testing (RADT) [17]. The approach to establishing the
diagnosis of acute streptococcal pharyngitis is discussed in detail separately.
(See "Evaluation of acute pharyngitis in adults", section on 'Identifying patients with GAS'.)
Antimicrobial therapy may also be administered to mitigate the clinical course of
pharyngitis due to group C and group G streptococci. The approach to antibiotic selection
is as outlined in the following sections. However, treatment need not continue for 10 days
since acute rheumatic fever is not a complication of infection due to these organisms; five
days of treatment is sufficient [2,18,19]. (See "Group C and group G streptococcal
infection".)

In general, antimicrobial therapy is of no proven benefit for treatment of pharyngitis due to

bacteria other than Streptococcus (with the exception of relatively rare infections caused
by other bacterial pathogens such as Corynebacterium diphtheriae and Neisseria
gonorrhoeae). Such therapy unnecessarily exposes patients to the expense and potential
hazards of antimicrobial drugs and contributes to the emergence of antibiotic-resistant
bacteria.

Timing of therapy — If clinical and/or epidemiologic factors point to a high index of

suspicion for GAS pharyngitis while laboratory results are pending, it is appropriate to
initiate empiric antimicrobial therapy. However, if laboratory testing does not confirm the
diagnosis of GAS pharyngitis, antimicrobial therapy should be discontinued.

In the natural history of GAS pharyngitis, the incubation period is two to four days. Fever
and constitutional symptoms usually resolve within three to four days, even in the absence
of antimicrobial therapy [16]. Clinical improvement has been observed up to 48 hours
sooner in patients receiving penicillin versus placebo within the first two days of illness [5-
9].

Treatment is warranted for patients with negative rapid antigen detection testing but
subsequent positive culture results whose symptoms are resolving, in order to reduce the
likelihood of transmission.

There is some concern that early therapy may suppress host antibody response and
thereby increase risk for recurrent pharyngitis. In a study of 142 children with presumed
GAS pharyngitis, those treated with penicillin at the initial office visit had a higher incidence
of recurrent infection than those for whom treatment was delayed at least 48 hours
(recurrent infection occurred eight times more frequently) [6].

Nonetheless, delaying treatment is not warranted in most cases of GAS tonsillopharyngitis.

It may be a useful strategy for patients who have frequent, recurrent, mild to moderate
infections to allow development of immunity to the infecting strain without increasing the
risk of acute rheumatic fever. Antibiotic therapy delayed for up to nine days following onset
of symptoms is still helpful for prevention of rheumatic fever (although may be less
effective for prevention of suppurative complications) [12]. However, this approach should
not be considered if the patient is severely ill or if highly virulent or rheumatogenic strains
are actively circulating within a community. Patients are considered no longer contagious
after 24 hours of antibiotic therapy [14].

Antibiotics for group A Streptococcus — Antibiotic options for treatment of GAS

pharyngitis include penicillin (and other related agents including ampicillin and amoxicillin),
cephalosporins, macrolides, and clindamycin [20]. Sulfonamides, fluoroquinolones, and
tetracyclines should NOT be used for treatment of GAS pharyngitis because of high rates
of resistance to these agents and their frequent failure to eradicate even susceptible
organisms from the pharynx.

Intramuscular penicillin is the only therapy that has been shown to prevent initial attacks of
rheumatic fever in controlled studies [13,21]. These studies were performed with penicillin
G procaine in oil containing aluminum monostearate; this preparation has since been
supplanted by penicillin G benzathine. There are data suggesting that penicillin G
benzathine is effective for primary prevention of rheumatic fever, although they are not
definitive [22]. Other antimicrobials have been shown to effectively eradicate GAS from the
upper respiratory tract, and it is assumed that such eradication is a surrogate for efficacy in
primary prevention of rheumatic fever.

Resistance — Antimicrobial resistance has not been a significant issue in the treatment of
GAS. No clinical isolate of GAS has demonstrated penicillin resistance, likely due to the
organism's lack of altered penicillin-binding proteins and/or inefficient gene transfer
mechanisms for resistance [23,24]. However, streptococcal strains tolerant to penicillin
(eg, strains inhibited but not killed by penicillin in vitro, with ratio of minimum bactericidal
concentration to minimum inhibitory concentration [MIC] of ≥32) have been described [25-
28]. The clinical significance of such strains is not clear; they have been isolated in the
setting of outbreaks in which penicillin treatment failure was observed, but there was no
difference in failure rates among tolerant and susceptible strains. (See "Antibiotic failure in
the treatment of streptococcal tonsillopharyngitis".)

There have been reports of relatively high levels of resistance to macrolide antibiotics in
some regions of the United States and Asia; given the increasing use of macrolides for
treatment of upper and lower respiratory tract infections, clinicians should be cognizant of
local patterns of antimicrobial resistance [29-39].

Selection — Oral penicillin V is the agent of choice for treatment of GAS pharyngitis given
its proven efficacy, safety, narrow spectrum, and low cost [2,40-44]. The appropriate
duration is 10 days of therapy; dosing is outlined in the Table (table 3). This approach is
extrapolated from studies performed in the 1950s demonstrating that treatment of
streptococcal pharyngitis with intramuscular penicillin prevents acute rheumatic fever
[13,21]. (See "Acute rheumatic fever: Treatment and prevention".)

Amoxicillin is often used in place of oral penicillin in children, since the taste of the
amoxicillin suspension is more palatable than that of penicillin. Some data suggest that
oral amoxicillin may be marginally superior to penicillin, most likely due to better
gastrointestinal (GI) absorption [45,46]. In addition, amoxicillin has activity against one-
third of the common pathogens that cause otitis media (which presents concurrently with
GAS tonsillopharyngitis in up to 15 percent of children, particularly those under four years
of age). Dosing is outlined in the Table (table 3). (See "Acute otitis media in children:
Treatment", section on 'Initial antimicrobial therapy'.)

Intramuscular penicillin G benzathine (single dose) may be administered to patients who

cannot complete a 10-day course of oral therapy or to patients at enhanced risk for
rheumatic fever (eg, those with history of previous rheumatic heart disease and/or living in
crowded conditions). Injections of penicillin G benzathine provide bactericidal levels
against GAS for 21 to 28 days. The addition of procaine penicillin alleviates some of the
discomfort associated with benzathine injections and may favorably influence the initial
clinical response. The preferred product in children is the combination of 900,000 units of
penicillin G benzathine plus 300,000 units of procaine penicillin (Bicillin C-R 900/300).
Dosing is outlined in the Table (table 3).

Cephalosporins are acceptable alternatives in patients with recurrent GAS infection but are
not recommended as first-line therapy in national guidelines [47-54]. Cephalosporins have
demonstrated better microbiologic and clinical cure rates than penicillin; these differences
appear to be greater among children than adults, and some favor use of first-generation
cephalosporins as first-line therapy in this group [55-57]. However, second- and third-
generation cephalosporins may facilitate development of antibiotic resistance and are not
favored as first-line therapy [48,49]. (See 'Recurrent infection' below.)
Antibiotic therapy directed against beta-lactamase–producing upper respiratory tract flora
(such as amoxicillin-clavulanate) remains controversial and is not indicated in patients with
acute pharyngitis, although it would be effective [2,58,59].

For patients with penicillin hypersensitivity, cephalosporins

(cefuroxime, cefpodoxime, cefdinir, and ceftriaxone) may be used [40,46-52], in the
absence of history of life-threatening allergic reaction to penicillin; cross reactivity with
penicillin is not likely for later-generation cephalosporins [47,60-62]. Macrolides
(azithromycin, clarithromycin, or erythromycin) are an acceptable alternative for penicillin-
allergic patients, depending on local resistance patterns, as resistance rates can be as
high as 20 percent [2,32,34-37,43,63-66].

There are a number of acceptable dosing regimens for azithromycin (table 3); these
include the following:

●Five-day course
•12 mg/kg (not to exceed 500 mg) on day 1, followed by 6 mg/kg (not to exceed
250 mg) on days 2 through 5 [36,43,63]
•12 mg/kg (not to exceed 500 mg) on days 1 through 5 [2,64,66]
●Three-day course: 20 mg/kg (not to exceed 500 mg) on days 1 through 3 [37,65,66]

Data from studies in adults form the basis for the five-day course of 12 mg/kg on day 1
followed by 6 mg/kg on days 2 through 5; data from studies in children form the basis for
the five-day course of 12 mg/kg and the three-day course of 20 mg/kg.

For the rare patient with an erythromycin-resistant strain of GAS who is unable to tolerate
beta-lactam agents, clindamycin is an appropriate choice [29,33,67]. (See "Allergy
evaluation for immediate penicillin allergy: Skin test-based diagnostic strategies and cross-
reactivity with other beta-lactam antibiotics".)

Duration — In general, the conventional duration of oral antibiotic therapy to achieve

maximal pharyngeal GAS eradication rates is 10 days, even though patients usually
improve clinically within the first few days of treatment [68,69]. If penicillin is discontinued
after three days of therapy, the probability of relapse is higher than if penicillin is
discontinued after seven days of treatment (50 versus 34 percent, respectively) [13,16,21].

Five days of therapy with cefpodoxime or cefdinir is an acceptable alternative approach,

with rates of bacteriologic and clinical cure of streptococcal pharyngitis comparable with
that of the conventional 10-day course of penicillin [37,43,70-82]. Three injections
of ceftriaxone on sequential days (or every other day) are needed for optimal eradication.

Azithromycin may be administered as a five-day or three-day regimen [34-37,65,66].

(See 'Selection' above.)

Attempts to treat GAS pharyngitis with a single daily dose of penicillin have been
unsuccessful. Although some data suggest that once-daily amoxicillin may be sufficient for
treatment of GAS pharyngitis, others have shown that this approach is not adequate for
effective eradication; further investigation is needed [83-86]. Among the alternative
agents, azithromycin and some cephalosporins
(including cefixime, cefpodoxime, cefadroxil, and cefdinir) are effective for eradication of
pharyngeal streptococci with once-daily dosing [75,87-90].

Antibiotics for other organisms — The differential diagnosis of acute pharyngitis is

outlined separately (table 4). (See "Evaluation of acute pharyngitis in adults".)
The approach to treatment of infection due to Streptococcus other than group A, influenza,
infectious mononucleosis, primary HIV infection, N. gonorrhoeae, Mycoplasma
pneumoniae, Chlamydia pneumoniae, and Corynebacterium diphtheriae is discussed
separately. (See related topics.)

The approach to treatment of infection due to Fusobacterium necrophorum is uncertain;

further study is needed to better define the role of F. necrophorum in the epidemiology of
pharyngitis and the associated risk between F. necrophorum pharyngitis and Lemierre's
syndrome. Some favor empiric treatment in the setting of negative diagnostic test results
but at least three Centor criteria (fever, tonsillar exudate, swollen tender cervical
adenopathy, or lack of cough) among patients 15 to 30 years of age, although it is
uncertain whether this approach is effective for prevention of Lemierre's syndrome [91-93].
In general, we favor treatment for pharyngitis only in the setting of a positive diagnostic
test [43]. Antibiotic therapy for pharyngitis attributed to F. necrophorum should consist of a
penicillin or cephalosporin; azithromycin lacks activity. (See "Suppurative (septic)
thrombophlebitis", section on 'Jugular vein' and "Evaluation of acute pharyngitis in adults",
section on 'Evaluation'.)

The antibiotics of choice for treatment of infection due to Arcanobacterium

haemolyticum are erythromycin or azithromycin; data are limited to case reports and in
vitro studies [94,95]. In vitro studies show most strains to be susceptible to beta-lactam
agents, although treatment failure may occur because of poor penetration into the
intracellular space [95]. Clindamycin, doxycycline, ciprofloxacin, and vancomycin are also
effective agents.

Follow-up — Patients with GAS pharyngitis should have improvement in clinical

symptoms within three to four days of initiating antibiotic therapy. Patients are considered
no longer contagious after 24 hours of antibiotic therapy [14]. Patients may return to
daycare, school, camp, or work after 24 hours of antibiotics; one study suggests children
treated with amoxicillin for streptococcal pharyngitis by 5:00 pm may be permitted to
attend school the following day if afebrile and clinically improved [15].

Failure to observe a clinical response to antibiotics should prompt diagnostic

reconsideration or the possibility of a suppurative complication. If acute streptococcal
pharyngitis was diagnosed by rapid testing, the result may represent a false-positive
finding; if the diagnosis was made by culture, the patient may be a pharyngeal carrier
whose symptoms are likely attributable to an alternate process. (See 'Carriers' below.)

In general, test of cure is not necessary for asymptomatic patients or their close contacts
following completion of a course of antimicrobial therapy. The majority of patients with
GAS remaining in their upper respiratory tracts after completing a course of antimicrobial
therapy are asymptomatic Streptococcus carriers [96,97].

However, follow-up test of cure is appropriate testing for asymptomatic index patients and
their asymptomatic household contacts in the following circumstances:

●Individuals with history of rheumatic fever

●Individuals who develop acute pharyngitis during an outbreak of acute rheumatic
fever or acute poststreptococcal glomerulonephritis [97]
●Spread of GAS among several family members

Asymptomatic patients and asymptomatic household contacts in the above circumstances

with positive laboratory results should receive a standard course of antimicrobial therapy
with one of the agents outlined above [98]. Repeat treatment should be administered with
an agent with greater beta-lactamase stability than the previous agent [58]. If a penicillin
was used for initial therapy, repeat treatment with amoxicillin-clavulanate or a first-
generation cephalosporin may be used; if initial treatment was with a first-generation
cephalosporin, a second- or third-generation cephalosporin may be used. First-generation
cephalosporins regimens include cephalexin and cefadroxil; second generation regimens
include cefprozil, cefuroxime, and cefaclor; third-generation cephalosporins
include cefdinir, cefpodoxime, and cefixime. (See "Evaluation of acute pharyngitis in
adults" and 'Antibiotics for group A Streptococcus' above.)

Recurrent infection — In the setting of recurrent acute pharyngitis with positive repeat
diagnostic testing, there are several possible explanations [96,98,99]:

●Persistence of Streptococcus carriage in the setting of viral infection

●Nonadherence with the prescribed antimicrobial regimen
●New infection with GAS acquired from household or community contacts
●Treatment failure (eg, repeat episode of pharyngitis caused by the original infecting
strain); treatment failure is rare.

In the setting of a second episode of acute pharyngitis with positive repeat diagnostic
testing, a repeat course of treatment is appropriate (table 3). Repeat treatment should be
administered with an agent with greater beta-lactamase stability than the previous agent
[58].

If adherence is uncertain, intramuscular penicillin G benzathine may be chosen as the

second course of therapy. If a full course of penicillin was completed as initial therapy, a
first-generation cephalosporin (such as cephalexin, cefadroxil) may be used; if a first-
generation cephalosporin was used for initial therapy, a second- or third-generation
cephalosporin (such as cefpodoxime, cefdinir) may be used. Alternative agents
include amoxicillin-clavulanate or clindamycin.

It is not necessary to perform follow-up testing after the second course of therapy unless
the patient remains or becomes symptomatic or unless special circumstances as outlined
above are present. (See 'Antibiotics for group A Streptococcus' above and 'Follow-
up' above.)

In the setting of multiple recurrent episodes, it may be difficult to distinguish true GAS
pharyngitis from viral pharyngitis in the setting of streptococcal carriage. It is likely that
most of these patients are carriers experiencing nonstreptococcal infections. This may be
discernible by evaluating for the presence of GAS during asymptomatic intervals and/or by
typing streptococcal isolates obtained during distinct episodes (with the expertise of a
specialized laboratory). In these circumstances, treatment with clindamycin or amoxicillin-
clavulanate may be beneficial since these agents have demonstrated high eradication
rates for pharyngeal streptococci carriage (table 3) [58,67,100]. (See 'Carriers' below.)

For patients with as many as six GAS infections in a single year or three to four episodes
in two consecutive years, tonsillectomy may be an appropriate therapeutic consideration
[101,102]. This was illustrated in a randomized trial including 187 children with recurrent
pharyngitis, of whom 95 were managed with tonsillectomy [101]. The incidence of
pharyngitis during the first two years of follow-up was significantly lower among the
tonsillectomy group. (See "Tonsillectomy and/or adenoidectomy in children: Indications
and contraindications", section on 'Recurrent throat infection'.)

Antibiotic failure in the treatment of streptococcal tonsillopharyngitis is discussed

separately. (See "Antibiotic failure in the treatment of streptococcal tonsillopharyngitis".)

PREVENTION
Carriers — In general, group A Streptococcus (GAS) resides in the oropharynx
of Streptococcus carriers in the absence of host immunologic response to the organism
[103]. In temperate climates during the winter and spring, up to 20 percent of
asymptomatic school-aged children may be carriers. About 25 percent of asymptomatic
individuals in the households of index patients harbor GAS in their upper respiratory tracts
[98]. Streptococcal carriage may persist for many months. (See "Antibiotic failure in the
treatment of streptococcal tonsillopharyngitis", section on 'Streptococcal carriage'.)

Carriers may demonstrate evidence of GAS in the upper respiratory tract during an
episode of viral pharyngitis, suggesting acute streptococcal pharyngitis. In these
circumstances, clinically distinguishing viral from streptococcal pharyngitis can be difficult.
Useful clues may include patient age, season, local epidemiology, and the nature of
presenting signs and symptoms. In addition, pharyngeal strep carriers tend to have low
antistreptolysin O (ASO) titers; they may be just above detectable. (See "Evaluation of
acute pharyngitis in adults".)

Streptococcus carriers are unlikely to spread the organism to close contacts and are at
very low risk for developing suppurative complications or acute rheumatic fever [103].
Moreover, eradication of GAS from the upper respiratory tract of carriers is much more
difficult than eradication of GAS from patients with acute infection [52,96,104]. In general,
except for the circumstances described above, Streptococcus carriers do not require
antimicrobial therapy. (See 'Follow-up' above.)

Foodborne illness — Streptococcal contamination of food has been implicated in

foodborne outbreaks of pharyngitis [105-109], and foodborne transmission of GAS
pharyngitis by asymptomatic food service workers with nasopharyngeal carriage has been
reported [108,110,111]. Factors that can reduce foodborne transmission of GAS
pharyngitis include thorough cooking, complete reheating, and use of gloves while
handling food [105,112].

Prophylaxis — Continuous antimicrobial prophylaxis is only appropriate for prevention of

recurrent rheumatic fever in patients who have experienced a previous episode of
rheumatic fever. (See "Acute rheumatic fever: Treatment and prevention", section on
'Secondary prevention (antibiotic prophylaxis)'.)

Vaccination — There is no vaccine against GAS available for clinical use, although
development of this preventive measure is under investigation [113,114]. An important
area of uncertainty is whether vaccine-induced antibodies may cross-react with host tissue
to produce nonsuppurative sequelae in the absence of clinical infection.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines

from selected countries and regions around the world are provided separately.
(See "Society guideline links: Streptococcal tonsillopharyngitis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education

materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are
written in plain language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These articles are best for
patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for
patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to
print or e-mail these topics to your patients. (You can also locate patient education articles
on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topics (see "Patient education: Sore throat in adults (The

Basics)" and "Patient education: Strep throat in children (The Basics)" and "Patient
education: Scarlet fever (The Basics)")
●Beyond the Basics topics (see "Patient education: Sore throat in children (Beyond
the Basics)" and "Patient education: Sore throat in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Goals of antimicrobial therapy for eradication of group A Streptococcus (GAS) from

the pharynx in the setting of acute streptococcal pharyngitis include:
•Reducing duration and severity of clinical signs and symptoms, including
suppurative complications
•Reducing incidence of nonsuppurative complications (eg, acute rheumatic
fever)
•Reducing transmission to close contacts by reducing infectivity (see 'Goals of
therapy' above)
●We recommend initiating treatment with antimicrobial therapy for patients with
symptomatic pharyngitis if the presence of group A streptococci in the pharynx is
confirmed by culture or rapid antigen detection testing (RADT) (Grade 1A).
(See 'Treatment' above.)
●We suggest initiating treatment with antimicrobial therapy for patients whose
clinical and/or epidemiologic factors point to a high index of suspicion for GAS
pharyngitis while laboratory results are pending (Grade 2B). (See 'Treatment' above.)
●Oral penicillin V is the agent of choice for treatment of GAS pharyngitis in many
clinical settings given its proven efficacy, safety, narrow spectrum, and low
cost. Amoxicillin is often used in place of oral penicillin in children, since the taste of
the amoxicillin suspension is more palatable than that of penicillin (table 3). First-
generation cephalosporins (such as cephalexin and cefadroxil) are acceptable
alternatives to penicillin and amoxicillin, especially in the setting of treatment failure or
beta-lactam hypersensitivity. (See 'Selection' above.)
●Although most patients improve clinically within the first few days of treatment, the
conventional duration of oral antibiotic therapy is 10 days to achieve maximal
pharyngeal GAS eradication rates. Intramuscular penicillin G benzathine may be
administered to patients who cannot complete a 10-day course of oral therapy.
(See 'Duration' above.)
●We suggest NOT treating with antibiotics for pharyngitis in the absence of positive
diagnostic data (Grade 2C). We suggest erythromycin or azithromycin for treatment
of pharyngitis due to Arcanobacterium haemolyticum(Grade 2C). (See 'Antibiotics for
other organisms' above.)
●In general, test of cure is not necessary for asymptomatic patients or their close
contacts following completion of a course of antimicrobial therapy, except in unique
circumstances. (See 'Follow-up' above.)
●We suggest a repeat course of treatment for patients with a repeat episode of acute
pharyngitis and positive repeat diagnostic testing (Grade 2C). Patients warranting a
repeat course of treatment may receive an agent with greater beta-lactamase stability
than the previous agent. (See 'Recurrent infection' above.)
●Patients who are long-term streptococcal carriers may develop multiple episodes of
pharyngitis due to viral infection. In such cases, repeatedly positive cultures or rapid
antigen tests for GAS may be misleading, and further treatment for streptococcal
pharyngitis may not be warranted. Carriers are unlikely to spread the organism to
close contacts and are at very low risk for developing suppurative complications or
acute rheumatic fever. Moreover, eradication of GAS from the upper respiratory tract
of carriers can be difficult and is not necessary. (See 'Carriers' above.)
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