What is the management for suspected streptococcal pharyngitis?

Management of Streptococcal Pharyngitis

Penicillin or amoxicillin for 10 days is the first-line treatment for streptococcal pharyngitis due to their proven efficacy, safety, narrow spectrum, and low cost. 1

Diagnosis Confirmation

The patient presents with classic symptoms of streptococcal pharyngitis:

• Sore throat with significant discomfort on swallowing
• Fever (37.6°C)
• Swollen tonsils with visible pus on the left tonsil
• Absence of viral symptoms (no cough, runny nose)

These findings are consistent with a high likelihood of Group A Streptococcal (GAS) pharyngitis. Confirmation with a rapid antigen detection test (RADT) or throat culture is recommended before starting antibiotics.

First-Line Treatment Options

For Non-Penicillin Allergic Patients:

1. Oral Options:

   • Penicillin V:

     • Children: 250 mg 2-3 times daily for 10 days
     • Adolescents/Adults: 250 mg 3-4 times daily OR 500 mg twice daily for 10 days 1, 2

   • Amoxicillin:

     • 50 mg/kg once daily (maximum 1,000 mg) for 10 days, OR
     • 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1

2. Parenteral Option:

   • Benzathine penicillin G (single intramuscular injection):
     • <27 kg: 600,000 units
     • ≥27 kg: 1,200,000 units 2, 1
     • Consider this option if compliance with oral therapy is a concern

For Penicillin-Allergic Patients:

1. Non-anaphylactic allergy:

   • First-generation cephalosporins (e.g., cephalexin) for 10 days 2, 1

2. Anaphylactic allergy:

   • Clindamycin for 10 days
   • Clarithromycin for 10 days
   • Azithromycin for 5 days 2, 1

Important note: While azithromycin is convenient due to its shorter course, it should not be the first choice as it has not been proven to prevent rheumatic fever, and there are concerns about increasing resistance 3.

Adjunctive Therapy

1. Pain and fever management:

   • Acetaminophen or NSAIDs for pain relief and fever reduction 1
   • Avoid aspirin in children due to risk of Reye syndrome 2, 1

2. Supportive care:

   • Adequate hydration
   • Warm salt water gargles for symptomatic relief (if patient is able to gargle)

Duration of Therapy

A full 10-day course of antibiotics is essential to:

• Prevent acute rheumatic fever
• Ensure complete eradication of GAS from the pharynx
• Prevent recurrence 2, 1, 4

Short-course therapy (≤5 days) with penicillin has been shown to be less effective for clinical cure and bacterial eradication compared to the standard 10-day course 5. While some studies suggest shorter courses with certain cephalosporins may be effective 6, 7, current guidelines still recommend the full 10-day course for penicillin or amoxicillin 2, 1.

Follow-Up Recommendations

1. No routine post-treatment testing:

   • Follow-up throat cultures or RADT are not routinely recommended after treatment 2, 1

2. When to seek further care:

   • If symptoms persist or worsen after 48-72 hours of antibiotic therapy
   • Development of new symptoms suggesting complications

Special Considerations for This Patient

• The patient is vaping and smoking 3-5 cigarettes daily - advise smoking cessation as it can irritate the throat and potentially delay healing
• The patient is breastfeeding a 16-month-old - penicillin and amoxicillin are considered safe during breastfeeding
• Monitor blood pressure as the patient has hypertension (current BP 132/96)

Common Pitfalls to Avoid

1. Inadequate duration of therapy:

   • Failure to complete the full 10-day course increases risk of treatment failure and complications 1, 4

2. Inappropriate use of macrolides:

   • Reserve for true penicillin allergies due to increasing resistance concerns 1, 3

3. Treating without confirmation:

   • While empiric therapy can be started based on strong clinical suspicion, confirmation with RADT or throat culture is recommended

4. Ignoring compliance issues:

   • Consider benzathine penicillin G injection if there are concerns about adherence to a 10-day oral regimen 2

By following these evidence-based recommendations, you can effectively manage this patient's streptococcal pharyngitis while minimizing complications and preventing recurrence.