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Pharyngitis: Treat Only Proven GAS: Physician Information Sheet (Pediatrics)

Careful Antibiotic Use

To avoid antibiotic resistance: treat only proven group A strep

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“If you are entirely comfortable selecting which pharyngitis patients to treat 10 days with penicillin, perhaps you don’t understand the situation.”

- Stillerman and Bernstein, 1961

Pharyngitis in Children1

  • Most sore throats are caused by viral agents.2

    Only 15 percent of pharyngitis is caused by group A strep

  • Clinical findings alone do not adequately distinguish Strep vs. Non-Strep pharyngitis.3

    BUT, prominent rhinorrhea, cough, hoarseness, conjuntivitis, or diarrhea suggest a VIRAL etiology. 4

  • Antigen tests (rapid Strep kits) or culture should be positive before beginning antibiotic treatment.

    Experts suggest confirming negative results on antigen tests with culture.5

Remember that most cases with clinical signs of strep, like exudate and adenopathy, are viral.

  • Experts discourage treatment pending culture results5-6, but if you do...
    • Make sure to stop antibiotics when culture is negative.
    • Discourage parents from saving antibiotics.
  • If an antibiotic is prescribed:
    • Use a penicillin as treatment for group A strep.7
    • NO group A strep are resistant to penicillin. Treatment is 90% effective at elimination of strep, and may be higher in the prevention of acute rheumatic fever (ARF). Carriers are at very low risk for both ARF and spreading infection.7
    • Use erythromycin if penicillin allergic.

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References

  1. Schwartz B, Marcy SM, Phillips WR, Gerber MA, Dowell SF, Pharyngitis-principles of judicious use of antimicrobial agents. Pediatrics 1998;101:171-174
  2. Tanz RR, Shulman ST. Diagnosis and treatment of group A streptococcal pharyngitis. Semin Pediatr Infect Dis 1995;6:69-78.
  3. Poses RM, Cebul RD, Collins M, et al. The accuracy of experienced physicians’ probability estimates for patients with sore throat: implications for decision making. JAMA 1985;254:925-29.
  4. Denson MR. Viral pharyngitis. Semin Pediatr Infect Dis 1995;6:62-68.
  5. American Academy of Pediatrics. Group A streptococcal infections. In: Pickering LK, ed. 2000 Red Book: Report of the Committee on infectious Diseases. 25th ed. Elk Grove, IL: American Academy of Pediatrics; 2000:528.
  6. Middleton DB, D’ Amico FD, Merenstein JH. Standardized symptomatic treatment versus penicillin as initial therapy for streptococcal pharyngitis. J Pediatr 1988;113:1089-94.
  7. Shulman ST, Gerber MA, Tanz RR, Markowitz M. Streptococcal pharyngitis: the case for penicillin therapy. Pediatr Infect Dis J 1994;13:1-7.

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