From the Guidelines
Asymptomatic group A streptococcal (GAS) pharyngeal colonization generally does not require treatment. In most cases, individuals who are carriers without symptoms should not receive antibiotics. This recommendation is based on the understanding that asymptomatic carriers have a low risk of developing complications or spreading the infection to others, as noted in the study by 1. The bacteria are typically present in lower numbers and are less virulent in carriers compared to those with active infections. Additionally, treating asymptomatic carriers has not been shown to prevent spread or reduce the incidence of subsequent GAS infections in most settings.
There are a few exceptions where treatment might be considered:
- In outbreaks of rheumatic fever or invasive GAS disease
- In communities with high rates of rheumatic fever
- When there is a family history of rheumatic fever
- In situations where multiple recurrent GAS infections occur within a family despite treatment of symptomatic individuals In these specific scenarios, a course of antibiotics such as penicillin V (250-500 mg twice daily for 10 days) or a single dose of benzathine penicillin G might be appropriate, as suggested by 1 and 1. The decision to treat should be individualized based on the specific clinical context and risk factors.
It's also important to note that differentiating a GAS carrier with an intercurrent viral infection from a patient with acute streptococcal pharyngitis can be challenging, as discussed in the study by 1. Helpful clues include patient age, season, local epidemiological characteristics, and the precise nature of the presenting signs and symptoms. However, in many instances, the clinician may not be able to distinguish persistent carriage from acute infection and will elect to administer another course of antimicrobials.
The most recent and highest quality study, 1, provides guidance on the treatment regimens for chronic carriers of Group A Streptococci, which can inform the decision to treat asymptomatic carriers in specific scenarios. Ultimately, the management of asymptomatic GAS pharyngeal colonization should prioritize the individual's risk factors and clinical context, as well as the potential benefits and harms of treatment, as emphasized by 1.
From the Research
Group A Streptococcal Pharyngitis Treatment
- The treatment of group A streptococcal pharyngitis is important in preventing acute rheumatic fever (ARF) 2.
- However, the treatment of asymptomatic carriers is still a topic of debate.
- A study found that in active sore throat management programmes, if the prevalence of GAS detection approaches the asymptomatic carriage rate, there may be little benefit from antibiotic treatment as the majority of culture-positive patients are likely carriers 2.
Asymptomatic Carriage
- The prevalence of asymptomatic GAS carriage was found to be around 10.5% in children from high-income countries 2.
- In low/middle-income countries, the carriage prevalence was detected to be lower, around 5.9% 2.
- Another study suggested that early recognition of group A streptococcal pharyngitis and appropriate management with benzathine penicillin is important in primary health care 3.
Antibiotic Treatment
- Antibiotics have been shown to be effective in reducing the incidence of acute rheumatic fever following an episode of suspected GAS pharyngitis 4.
- A meta-analysis found that antibiotic treatment reduced the risk of recurrence of rheumatic fever substantially, with a risk ratio of 0.39 5.
- However, the use of antibiotics in asymptomatic carriers is still a topic of debate, and more research is needed to determine the benefits and risks of treatment in this population.
Clinical Considerations
- Clinical guidelines for the prescription of antibiotics for GAS pharyngitis vary, and the decision to treat asymptomatic carriers should be made on a case-by-case basis 2, 6.
- The risk of developing rheumatic heart disease (RHD) later in life is a significant concern, and antibiotic prophylaxis may be beneficial in reducing this risk 5.
- However, the majority of studies on this topic were conducted over 50 years ago, and more recent research is needed to inform current clinical practice.