What is the treatment for Group A Streptococcal (GAS) infections in pediatric patients?

Treatment of Group A Streptococcal (GAS) Infections in Pediatric Patients

For pediatric Group A Streptococcal pharyngitis, oral penicillin V (250 mg 2-3 times daily) or amoxicillin (50 mg/kg once daily, maximum 1000 mg) for a full 10-day course is the recommended first-line treatment. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Use the Centor Criteria to assess likelihood of GAS infection:

  • Tonsillar exudates
  • Tender anterior cervical lymph nodes
  • Lack of cough
  • Fever 1

• Patients with 0-2 criteria are unlikely to have GAS infection and don't require testing

• Patients with 3-4 criteria should be tested with rapid antigen detection test (RADT) and/or throat culture 1

First-Line Treatment Options

Oral Antibiotics

• Penicillin V:

  • Children: 250 mg 2-3 times daily for 10 days
  • Adolescents: 500 mg 2-3 times daily for 10 days 1

• Amoxicillin:

  • 50 mg/kg once daily (maximum 1000 mg) OR
  • 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2

Amoxicillin may offer slightly better bacteriologic and clinical cure rates compared to penicillin V (76% vs 64% bacteriologic cure rate) 3, but both are considered effective first-line options.

Injectable Option

• Benzathine penicillin G (intramuscular): For patients with anticipated compliance issues 4

Alternative Treatments for Penicillin-Allergic Patients

For patients with penicillin allergy, the following alternatives are recommended:

• Cephalosporins (if no history of anaphylaxis to penicillin):

  • Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1

• Macrolides/Azalides:

  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days
  • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1

Caution: Macrolide resistance has been reported in some geographic regions 5, so these should be used with caution where resistance patterns are concerning.

Treatment Duration and Compliance

• A full 10-day course of antibiotics is crucial (except for azithromycin, which is 5 days) to:

  • Prevent acute rheumatic fever
  • Ensure complete GAS eradication
  • Reduce risk of treatment failure 1, 2

• Patients must complete the full course even if symptoms improve before completion 1

Symptomatic Treatment

In addition to antibiotics, symptomatic relief can be provided with:

• NSAIDs or acetaminophen for pain and fever
• Warm salt water gargles
• Throat lozenges 1

Special Considerations

Persistent GAS Carriage

For children with persistent GAS carriage (10-20% of school-aged children):

• Most carriers have low risk of immune-mediated complications
• Eradication therapy may be considered for high-risk individuals:
  • Penicillin plus rifampin OR
  • Clindamycin monotherapy 6

Recurrent Tonsillitis

Tonsillectomy should be considered based on the Paradise criteria:

• ≥7 well-documented, adequately treated episodes in the preceding year, OR
• ≥5 such episodes in each of the preceding 2 years, OR
• ≥3 such episodes in each of the preceding 3 years 1

Prevention of Rheumatic Fever

Primary prevention of acute rheumatic fever is accomplished through proper identification and adequate antibiotic treatment of GAS pharyngitis. Patients with a history of rheumatic fever require continuous antimicrobial prophylaxis to prevent recurrences 4.

Key Pitfalls to Avoid

1. Inadequate treatment duration: Failing to complete the full 10-day course increases risk of treatment failure and complications
2. Misdiagnosis: Viral pharyngitis symptoms (cough, rhinorrhea, hoarseness, oral ulcers) suggest against GAS infection
3. Inappropriate macrolide use: In areas with high macrolide resistance, these should not be first-line therapy
4. Neglecting follow-up: For high-risk patients or treatment failures, follow-up testing may be necessary