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 by looking for the following:
- 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
- No cough
Diagnosis
Not High-Risk for Rheumatic Fever
Testing (intermediate or high probability of group A beta hemolytic streptococci [GABHS]) and Treatment
Throat Culture
- If throat culture is positive, use antibiotics.
- If throat culture is negative, use symptomatic treatment only. Avoid antibiotics.
OR
Rapid Screen
- 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 older
High Risk for Rheumatic Fever or Household Contact with History of Rheumatic Fever or Confirmed Strep
Start antibiotics immediately. Obtain throat culture. If negative, stop antibiotics.
Treatment
(See
www.med.umich.edu/1info/FHP/practiceguides/pharyngitis/pharyn.pdf for detailed drug and dosing recommendations)
Preferred Treatment for Strep Pharyngitis
- Penicillin VK: 250–500 mg twice or three times daily (bid-tid) x 10 days
- Amoxicillin: 40 mg/kg/day divided bid-tid x 10 days [A] or 750 mg daily x 10 days if compliance is a concern
- Benzathine penicillin G intramuscularly (IM) x 1
- If allergic to penicillin: erythromycin ethyl succinate: 40 mg/kg/day two-four times daily (bid-qid) (max 1 g/day) x 10 days or azithromycin
- With oral antibiotics, a full 10 day course is required (exception: azithromycin)
Alternative Treatment for Strep Pharyngitis
- Cephalexin
Re-Evaluation/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 Recommendations
- Randomized controlled trials
- Controlled trials, no randomization
- Observational studies
- Opinion of expert panel
