Do you treat both partners for streptococcal pharyngitis (strep throat) when one has a positive test result and the other has a negative test result but is symptomatic?

From the Guidelines

For streptococcal pharyngitis (strep throat), I recommend treating only the partner with the positive test result, not the symptomatic partner with a negative test. The standard treatment for confirmed strep throat is penicillin V potassium (250-500 mg orally twice daily for 10 days) or amoxicillin (500 mg twice daily or 1000 mg once daily for 10 days) 1. For penicillin-allergic patients, alternatives include cephalexin (if no anaphylactic reaction to penicillin), clindamycin, azithromycin, or clarithromycin. A negative rapid strep test or throat culture in a symptomatic individual suggests their symptoms are likely viral or due to another cause, not Group A Streptococcus.

Treating the test-negative partner would constitute inappropriate antibiotic use, potentially contributing to antibiotic resistance and exposing them to medication side effects without clear benefit 1. The symptomatic partner with a negative test should be managed based on their likely diagnosis, which may involve supportive care for viral pharyngitis rather than antibiotics. If clinical suspicion remains high despite a negative rapid test, a throat culture can be performed for confirmation before initiating antibiotics 1.

Key considerations in managing streptococcal pharyngitis include:

• Confirming the diagnosis with a rapid antigen detection test and/or culture of a throat swab
• Using antibiotics only for confirmed cases to avoid unnecessary use and resistance
• Choosing the appropriate antibiotic regimen based on patient factors such as allergy history
• Providing supportive care for symptomatic partners with negative tests, as their symptoms are likely due to a viral cause.

From the Research

Treatment of Streptococcal Pharyngitis

• The decision to treat both partners for streptococcal pharyngitis when one has a positive test result and the other has a negative test result but is symptomatic depends on various factors, including the clinical presentation and the risk of transmission 2, 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 2.
• If the symptomatic partner has a negative rapid antigen test result, a throat culture may be recommended to confirm the diagnosis 2, 3.
• Penicillin and amoxicillin are first-line antibiotics for the treatment of streptococcal pharyngitis, with a recommended course of 10 days 2, 3, 4.
• The treatment of the asymptomatic partner is not recommended unless they have a positive test result or are at high risk of transmission 3, 5.

Diagnostic Considerations

• The diagnosis of streptococcal pharyngitis is based on a combination of clinical presentation, physical examination, and diagnostic tests, including rapid antigen detection tests and throat culture 2, 3, 5.
• 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.
• The sensitivity and specificity of rapid antigen detection testing have improved significantly, but throat culture is still considered the diagnostic standard 3, 5.

Antibiotic Treatment

• The choice of antibiotic and duration of treatment depend on the severity of the infection, the patient's age and medical history, and the presence of any allergies or resistance patterns 2, 3, 4, 6.
• Azithromycin and clarithromycin are not recommended as first-line antibiotics due to significant resistance in some parts of the United States 2, 6.
• The efficacy and safety of amoxicillin 1 g b.i.d. for 6 days were not statistically different from those of penicillin V 1 MU t.i.d. for 10 days in the treatment of streptococcal tonsillitis in adults 4.