Does Group A streptococcal (GAS) pharyngitis require treatment in children?

Group A Streptococcal Pharyngitis Treatment in Children

Group A streptococcal (GAS) pharyngitis in children should be treated with antibiotics to prevent acute rheumatic fever, prevent suppurative complications, improve clinical symptoms, reduce transmission, and minimize adverse effects of inappropriate antimicrobial therapy. 1

Diagnosis

Proper diagnosis is essential before initiating treatment:

• Clinical features alone cannot reliably differentiate GAS from viral pharyngitis
• Laboratory confirmation is necessary through:
  • Rapid antigen detection test (RADT)
  • Throat culture if RADT is negative (particularly in children and adolescents) 1

Children typically present with:

• Sudden onset of sore throat
• Pain with swallowing
• Fever
• Tonsillopharyngeal erythema
• Lymphadenitis 1

Note: GAS pharyngitis is uncommon in children <3 years old and testing is generally not recommended in this age group unless specific risk factors exist 1

Treatment Recommendations

First-line Treatment:

• Penicillin V is the recommended first-line therapy:
  • Children: 250 mg 2-3 times daily for 10 days
  • Adolescents: 500 mg 2-3 times daily for 10 days 1, 2, 3

Alternative Treatments:

• For penicillin allergy (non-anaphylactic):
  • First-generation cephalosporins (e.g., cephalexin)
• For immediate/anaphylactic penicillin hypersensitivity:
  • Clindamycin: 20-30 mg/kg/day in 2-4 divided doses for 10 days
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 2, 3

Treatment Duration:

• Standard treatment duration is 10 days for penicillin to ensure eradication of the organism 1, 4
• Azithromycin can be given for 5 days at appropriate dosages 3, 5

Rationale for Treatment

Treatment of GAS pharyngitis is recommended primarily to:

1. Prevent acute rheumatic fever (ARF): Treatment within 9 days of symptom onset effectively prevents this serious complication 1
2. Prevent suppurative complications: Including peritonsillar abscess, cervical lymphadenitis, and mastoiditis
3. Improve clinical symptoms: Reduces duration of symptoms and speeds recovery
4. Reduce transmission: Decreases spread to close contacts 1
5. Prevent post-streptococcal glomerulonephritis: Though treatment does not prevent this complication 1

Important Considerations

Follow-up Testing

• Routine follow-up cultures after treatment are not recommended unless symptoms persist or recur 2

Return to School

• Children should complete a full 24 hours of antibiotics before returning to school or daycare to reduce transmission risk 6

Treatment Failures

• Bacteriologic treatment failures occur in up to 35% of patients treated with penicillin V, particularly in children <6 years old 5
• Poor compliance with the standard 10-day penicillin treatment is likely a major factor 5
• For treatment failures, consider alternative antibiotics such as cephalosporins or azithromycin 7

Recent Research

• A recent study suggests that symptoms may resolve without antibiotics, but this approach is not recommended due to the risk of serious complications, particularly acute rheumatic fever 8
• The established standard of care remains antibiotic treatment for confirmed GAS pharyngitis 1

Conclusion

Despite being a self-limited illness in most cases, GAS pharyngitis requires antibiotic treatment in children to prevent serious complications, particularly acute rheumatic fever. Penicillin remains the first-line treatment, with appropriate alternatives available for those with allergies or treatment failures.