The level of evidence grades (A-D) are provided for the most significant recommendations and are defined at the end of the "Major Recommendations" field.
Assessment
Assess past history of rheumatic fever (especially carditis or valvular disease) or household contact with a history of rheumatic fever to identify high-risk patients.
Assess the likelihood of strep pharyngitis using the following items:
- Sudden onset
- Sore throat
- Fever
- Patchy discrete exudate
- Headache
- Nausea, vomiting, and abdominal pain
- Inflammation of pharynx and tonsils
- Tender, enlarged anterior cervical nodes
- Patient aged 5–15 years
- Presentation in winter or early spring
- History of exposure
Diagnosis
Not High-Risk Patients
Probability of group A beta hemolytic streptococci (GABHS): Low
Testing: None
Treatment: Symptomatic treatment only. Avoid antibiotics.
Probability of GABHS: Intermediate or High
Testing: Throat Culture (TC) OR Rapid Screen
Treatment: If TC is positive, use antibiotics.
If TC is negative, use symptomatic treatment only. Avoid antibiotics.
If treatment is started and culture result is negative, stop antibiotics.
If Rapid Screen is positive, use antibiotics.
If Rapid Screen is negative, culture1 and only use antibiotics if throat culture is positive.
1Culture optional for age 16 and over
High Risk Patients (history of rheumatic fever or household contact)
Start antibiotics immediately. If throat culture is obtained and is negative, stop antibiotics.
Treatment
Preferred Treatment for Strep Pharyngitis
- Penicillin VK: 250–500 mg twice or three times daily (bid-tid) x 10 days
- Amoxicillin: 20–40 mg/kg/day divided tid x 10 days [A]
- Benzathine penicillin G intramuscularly (IM) x 1: 600,000 units for weight < 60 lbs; 1.2 million units for weight > 60 lbs
- If allergic to penicillin: erythromycin ethyl succinate: 40 mg/kg/day two-four times daily (bid-qid) (max 1 g/day) x 10 days
- With oral antibiotics, a full 10 day course is required
Alternative Treatment for Strep Pharyngitis
- Cephalexin 15 to 50 mg/kg/day divided bid or tid x 10 days
Re-Evaluate/Referral
- If failure to respond clinically after 48 hours of treatment, rule out peritonsillar or retropharyngeal abscess. If present, prompt otolaryngology (ENT) evaluation is recommended.
- Assess the potential for a compliance problem.
Definitions:
Levels of Evidence for the Most Significant Recommendation
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
