What is the appropriate management for a 40-year-old female with pharyngitis and a positive rapid streptococcal test?

From the Guidelines

The patient should be prescribed amoxicillin 50 mg/kg once daily (max = 1000 mg) for 10 days, as it is a recommended antibiotic regimen for Group A Streptococcal pharyngitis, according to the Infectious Diseases Society of America guidelines 1. This recommendation is based on the patient's positive rapid strep test and the need for antibiotic treatment to prevent complications such as rheumatic fever or post-streptococcal glomerulonephritis. Some key points to consider in the management of this patient include:

• The patient's recent history of strep infection, for which she was given amoxicillin, does not preclude the use of amoxicillin again, as the current infection is a new episode.
• The patient should complete the entire antibiotic course, even if symptoms improve, to ensure eradication of the infection.
• For symptom relief, the patient can continue to take ibuprofen 400-600 mg every 6 hours as needed for pain and inflammation.
• Throat lozenges and warm salt water gargles can provide additional comfort.
• The patient should stay hydrated and rest until fever-free for 24 hours.
• If symptoms worsen or don't improve within 48-72 hours of starting antibiotics, the patient should return for reevaluation. It is essential to note that Group A Streptococcal pharyngitis requires treatment because, unlike viral pharyngitis, it can lead to serious complications if left untreated, as highlighted in the guidelines from the American Heart Association 1. In addition, the patient's treatment should be guided by the most recent and highest-quality evidence, which in this case is the 2012 update by the Infectious Diseases Society of America 1, which provides recommendations for the diagnosis and management of Group A Streptococcal pharyngitis.

From the FDA Drug Label

Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy. Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS): Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14Day 30 Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%) Penicillin V242/332 (73%)206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%) Penicillin V284/338 (84%)241/325 (74%)

Azithromycin is effective in treating pharyngitis/tonsillitis caused by Streptococcus pyogenes. The clinical success rate for azithromycin was 98% at Day 14 and 94% at Day 30, with bacteriologic eradication rates of 95% at Day 14 and 77% at Day 30. Azithromycin may be considered as an alternative to first-line therapy in individuals who cannot use first-line therapy 2, 2, 2.

From the Research

Patient Presentation

• The patient is a 40-year-old female presenting with a sore throat for 3 days, accompanied by mild rhinorrhea and headache.
• She has a history of strep throat approximately 2 months ago, which was treated with amoxicillin, and reports full resolution of symptoms.
• The patient denies any fever, vomiting, or cough, and has taken ibuprofen to treat her symptoms.
• A rapid strep test was positive.

Diagnosis and Treatment

• According to 3, guidelines recommend using clinical decision rules to assess the risk of group A beta-hemolytic streptococcal infection, followed by rapid antigen testing if a diagnosis is unclear, before prescribing antibiotics.
• The patient's symptoms, such as sore throat and mild rhinorrhea, are consistent with streptococcal pharyngitis, as described in 4 and 5.
• Penicillin and amoxicillin are recommended as first-line antibiotics for the treatment of streptococcal pharyngitis, with a recommended course of 10 days, as stated in 3 and 6.
• Azithromycin is not recommended as a first-line treatment due to significant resistance in some parts of the United States, as mentioned in 3, and its lower bacteriologic eradication rates compared to penicillin V, as shown in 7.

Management

• The patient's positive rapid strep test result confirms the diagnosis of streptococcal pharyngitis.
• Given the patient's history of strep throat treated with amoxicillin 2 months ago, and the current positive rapid strep test result, it is likely that the patient has a recurrent infection, as discussed in 4 and 5.
• The patient should be treated with a recommended antibiotic, such as penicillin or amoxicillin, for a duration of 10 days, as suggested in 3 and 6.