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Updated Guidelines for Diagnosis and Management of Strep Pharyngitis

The 2012 IDSA guidelines strongly emphasize using testing to guide treatment.

In its first update in 10 years, the Infectious Diseases Society of America (IDSA) issued revised guidelines for the diagnosis and treatment of Group A streptococcal (GAS) pharyngitis.

To establish the diagnosis, testing is not indicated in patients with features highly suggestive of a viral cause (rhinorrhea, cough, oral ulcers, overt viral features) or in children younger than 3 years. Because clinical features inadequately discriminate between viral and GAS pharyngitis in all other cases, a rapid antigen detection test (RADT) should be performed. No treatment is recommended for patients with negative RADT results, with the exception of children and adolescents, who should have a culture performed to guide treatment. Antistreptococcal antibody testing is not recommended.

Recommended treatment is a 10-day course of penicillin or amoxicillin. For patients who are allergic but not anaphylactically sensitive to penicillin, a 10-day course of a first-generation cephalosporin should be used; for patients who are anaphylactically sensitive to penicillin, clindamycin or clarithromycin for 10 days or azithromycin for 5 days is recommended.

The guidelines support the use of analgesics and antipyretics but do not endorse the use of adjunctive corticosteroid therapy.

Comment: These guidelines focus on minimizing inappropriate antibiotic treatment of non-GAS pharyngitis by emphasizing testing in appropriate patients and treatment based on the results. Every emergency department should have a way to deal with delayed results, such as positive cultures from abscesses and positive assays for gonorrhea and chlamydia. Antibiotic stewardship is important, and these guidelines should be respected.

— Diane M. Birnbaumer, MD, FACEP

Published in Journal Watch Emergency Medicine November 16, 2012

Citation(s):

Shulman ST et al. Clinical practice guideline for the diagnosis and management of Group A Streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012 Nov 15; 55:1279.

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Reader Remarks:

Review and add to remarks on this article

• Viral Pharyngitis
  Schlomo Mizrahi, 19 Nov 2012 3:21 PM EST
  Specialty: Oral & Maxillofacial Surgery
  It is a common practice in many of our clinics to take a swab culture in all cases of pharyngitis.... [more]
• viral pharyngitis
  Bilguis A., 30 Nov 2012 10:34 AM EST
  Specialty: Pediatrics
  If the culture is positive for Group A, b-hemolytic strep. then AB should be given as they can prevent rheumatic... [more]
• Strep in kids under 3
  SL B, 20 Dec 2012 12:13 PM EST
  Specialty: Emergency Medicine
  A friend's child was seen 2x for irritability, drooling, poor feeding etc and her Peds Dr. told the mother the... [more]

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