When should antibiotic therapy be started in a child presenting with severe sore throat and fever, after a throat swab has been taken for Group A beta-hemolytic streptococcal (GABHS) infection?

From the Guidelines

Antibiotic therapy should be started immediately in a child presenting with severe sore throat and fever after a throat swab has been taken if there is strong clinical suspicion of Group A beta-hemolytic streptococcal (GABHS) infection, rather than waiting for culture results. The recommended first-line treatment is penicillin V (phenoxymethylpenicillin), typically dosed at 250 mg twice daily for children under 12 years and 500 mg twice daily for older children, for a 10-day course, as suggested by the Infectious Diseases Society of America guidelines 1. For penicillin-allergic patients, alternatives include azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days) or clindamycin (7 mg/kg three times daily for 10 days) 1.

Some key points to consider in the management of GAS pharyngitis include:

• The importance of accurate diagnosis to prevent inappropriate antimicrobial therapy in cases of non-streptococcal pharyngitis 1
• The role of adjunctive therapy, such as analgesic/antipyretic agents like acetaminophen or NSAIDs, in managing symptoms 1
• The potential for antimicrobial resistance, although penicillin resistance has not been a significant issue in the treatment of GAS pharyngitis in the United States 1

Prompt antibiotic initiation is justified because early treatment reduces symptom duration, decreases contagiousness, and most importantly, prevents serious complications like rheumatic fever and post-streptococcal glomerulonephritis, as highlighted in the guidelines 1. If the throat culture returns negative, antibiotics can be discontinued, but completing the full course is essential if GABHS is confirmed to ensure complete eradication of the bacteria and prevent complications. Supportive care with adequate hydration, rest, and appropriate pain management with acetaminophen or ibuprofen should also be provided alongside antibiotic therapy.

From the FDA Drug Label

Therapy with azithromycin may be initiated before results of these tests are known; once the results become available, antimicrobial therapy should be adjusted accordingly

The antibiotic therapy can be started before the throat swab results are available, but the treatment should be adjusted based on the results of the tests.

• Key consideration: The decision to start antibiotic therapy should be based on the clinical judgment of the healthcare provider, taking into account the severity of the symptoms and the likelihood of a bacterial infection.
• Important note: The FDA drug label does not provide a specific timeframe for when to start antibiotic therapy in a child presenting with severe sore throat and fever, after a throat swab has been taken for Group A beta-hemolytic streptococcal (GABHS) infection 2.

From the Research

Diagnosis and Treatment of Group A Beta-Hemolytic Streptococcal Pharyngitis

• The diagnosis of Group A beta-hemolytic streptococcal (GABHS) pharyngitis is typically confirmed by microbiologic testing (e.g., culture, rapid antigen detection test, molecular point-of-care test) of a throat swab specimen prior to the initiation of antimicrobial therapy 3.
• Clinical score systems such as the Centor score and McIssac score have been developed to help clinicians decide which patients should undergo diagnostic testing and reduce the unnecessary use of antimicrobials 3, 4.

Initiation of Antibiotic Therapy

• Antibiotic therapy should be initiated without delay once the diagnosis is confirmed 3.
• Oral penicillin V and amoxicillin remain the drugs of choice for the treatment of GABHS pharyngitis 3, 4.
• For patients who have a non-anaphylactic allergy to penicillin, oral cephalosporin is an acceptable alternative 3.
• For patients with a history of immediate, anaphylactic-type hypersensitivity to penicillin, oral clindamycin, clarithromycin, and azithromycin are acceptable alternatives 3.

Choice of Antibiotic

• There is low-certainty evidence that compared with penicillin, carbacephem may provide better symptom resolution post-treatment in adults and children 5.
• Cephalosporins and macrolides may be as effective as penicillin for symptom resolution, but the evidence is uncertain 5.
• Azithromycin may be as effective as amoxicillin for symptom resolution in children, but the evidence is very low-certainty 5.

General Practice in New Zealand

• In the context of general practice in New Zealand, the initiation of antibiotic therapy for a child presenting with severe sore throat and fever, after a throat swab has been taken for GABHS infection, should be guided by the results of the microbiologic testing and the clinical judgment of the healthcare provider 3, 6.