From the Guidelines
Tonsillectomy is recommended for patients with recurrent strep pharyngitis, defined as at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, with documentation of sore throat and one of the following: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus 1. Management of recurrent strep pharyngitis requires a systematic approach, considering the frequency and severity of episodes, as well as the presence of documented Group A Streptococcal (GAS) infections.
Key Considerations
- For antibiotic therapy, amoxicillin remains a viable option, but the most recent guideline recommends against tonsillectomy solely to reduce the frequency of GAS pharyngitis 1.
- For penicillin-allergic patients, alternatives such as cephalexin or azithromycin may be considered.
- Recurrent cases may benefit from clindamycin, which can be effective against beta-lactamase-producing organisms that can protect GAS.
- Testing family members for asymptomatic carriage and considering prophylactic antibiotics in select cases may also be important.
Diagnosis and Treatment
- Distinguishing between actual recurrent infections and a carrier state with concurrent viral illnesses is crucial, as carriers generally do not require treatment unless they are a source of infection to others 1.
- The 2019 clinical practice guideline update recommends tonsillectomy for recurrent throat infection with documentation, emphasizing the need for appropriate documentation and shared decision-making 1.
- The guideline also highlights the importance of considering the frequency and clinical features of throat infection episodes to ensure clinical benefits consistent with those achieved in randomized controlled trials.
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 is often effective in the eradication of susceptible strains of Streptococcus pyogenes from the nasopharynx Data establishing efficacy of azithromycin in subsequent prevention of rheumatic fever are not available.
The management of recurrent strep pharyngitis may involve the use of azithromycin as an alternative to first-line therapy in individuals who cannot use first-line therapy. Azithromycin is often effective in eradicating susceptible strains of Streptococcus pyogenes from the nasopharynx. However, there is no data available on the efficacy of azithromycin in preventing subsequent rheumatic fever 2, 2, 2.
- Key points:
- Azithromycin can be used as an alternative to first-line therapy for pharyngitis/tonsillitis caused by Streptococcus pyogenes.
- Azithromycin is effective in eradicating susceptible strains of Streptococcus pyogenes.
- No data is available on the efficacy of azithromycin in preventing subsequent rheumatic fever.
From the Research
Management of Recurrent Strep Pharyngitis
- The management of recurrent strep pharyngitis involves the use of antibiotics, with penicillin and amoxicillin being the first-line treatments 3, 4.
- Cephalosporins are recommended for patients with non-anaphylactic allergies to penicillin 3, 4.
- Azithromycin and clarithromycin are not recommended due to significant resistance in some parts of the United States 4.
- Tonsillectomy is rarely recommended as a preventive measure, with thresholds of seven episodes of streptococcal pharyngitis in 1 year, five episodes in each of the past 2 years, or three episodes in each of the past 3 years being considered for surgery 4.
Antibiotic Treatment Options
- Penicillin and amoxicillin are effective in treating strep pharyngitis, with a recommended course of 10 days 3, 4.
- Cephalosporins may be more effective than penicillin in eradicating group A beta-hemolytic streptococcus (GABHS) 3, 5.
- Azithromycin may be associated with lower levels of bacteriologic eradication compared to penicillin V 6.
- Carbacephem may be more effective than penicillin for symptom resolution in adults and children 5.
Clinical Decision Rules
- The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 3.
- Clinical decision rules, such as the Centor score, can be used to assess the risk of group A beta-hemolytic streptococcal infection 4.
- Fever, tonsillar exudate, cervical lymphadenitis, and patient ages of 3 to 15 years increase clinical suspicion of strep pharyngitis 4.