From the Guidelines
Post-streptococcal disorders can be effectively prevented and managed with proper identification and treatment of group A streptococcal pharyngitis, and penicillin is the treatment of choice due to its cost-effectiveness, narrow spectrum of activity, and proven efficacy, as stated in the 2009 American Heart Association guidelines 1. The most significant post-streptococcal conditions include acute rheumatic fever and post-streptococcal glomerulonephritis, which develop due to an abnormal immune response to streptococcal antigens. For suspected strep throat, treatment with penicillin V 500 mg twice daily for 10 days is recommended to prevent these complications. Alternatives for penicillin-allergic patients include azithromycin 500 mg on day 1, then 250 mg daily for 4 more days, or clindamycin 300 mg three times daily for 10 days, as suggested by the 2012 Infectious Diseases Society of America guidelines 1. If post-streptococcal complications have already developed, treatment depends on the specific condition. For rheumatic fever, anti-inflammatory medications like aspirin or prednisone are used for symptoms, plus antibiotics to eradicate any remaining bacteria. Patients with a history of rheumatic fever require long-term prophylactic antibiotics, typically penicillin G benzathine 1.2 million units intramuscularly every 4 weeks, as recommended by the American Heart Association 1. Post-streptococcal glomerulonephritis generally resolves with supportive care, though antibiotics are given to clear any persistent infection. Key considerations in managing post-streptococcal disorders include:
- Accurate diagnosis of group A streptococcal pharyngitis using throat culture or rapid antigen detection testing (RADT) 1
- Prompt treatment with penicillin or alternative antibiotics for penicillin-allergic patients
- Long-term prophylactic antibiotics for patients with a history of rheumatic fever
- Supportive care and antibiotics for post-streptococcal glomerulonephritis.
From the Research
Post-Streptococcal Complications
- Post-streptococcal complications can occur after a streptococcal infection, including acute rheumatic fever, post-streptococcal reactive arthritis, pediatric autoimmune neuropsychiatric disorders, and post-streptococcal glomerulonephritis 2.
- These complications are more common in children and can occur after streptococcal pharyngitis or scarlet fever 3.
- The diagnosis of post-streptococcal complications requires evidence of a recent streptococcal infection, such as a positive throat culture or rapid antigen detection test, and the presence of specific clinical symptoms 4.
Clinical Presentation
- Acute rheumatic fever is characterized by arthritis, carditis, cutaneous disease, chorea, and subsequent acquired valvular disease 2, 3.
- Post-streptococcal reactive arthritis is a non-migratory arthritis that can affect any joint and typically does not respond to aspirin 5, 2.
- Pediatric autoimmune neuropsychiatric disorders can manifest as obsessive-compulsive disorders, tic disorders, dystonia, chorea encephalitis, and dystonic choreoathetosis 2, 3.
- Post-streptococcal glomerulonephritis can present with a range of symptoms, from asymptomatic microscopic hematuria to gross hematuria, edema, hypertension, proteinuria, and elevated serum creatinine levels 2.
Prevention and Treatment
- Primary prophylaxis is key to limiting the spread of streptococcal infections and preventing post-streptococcal complications 6.
- Treatment of post-streptococcal complications typically involves nonsteroidal anti-inflammatory drugs, corticosteroids, or other medications depending on the specific condition 5, 2.
- Prevention of streptococcal pharyngitis and post-infection systemic complications is an area of ongoing research, with potential future developments including the creation of an anti-Streptococcus pyogenes vaccine 4.