Symptoms and Treatment of Group A Streptococcal Infections in Children
Group A streptococcal (Strep A) infections in children present with distinct symptoms and require prompt diagnosis and treatment with penicillin or amoxicillin to prevent complications and reduce symptom duration.
Clinical Presentation of Strep A in Children
Key Symptoms
- Sudden onset of sore throat
- Pain with swallowing
- Fever
- Headache
- Nausea, vomiting, or abdominal pain
- Tonsillopharyngeal inflammation
- Patchy tonsillopharyngeal exudates
- Palatal petechiae
- Tender anterior cervical lymphadenitis (swollen lymph nodes)
- Scarlatiniform rash (in some cases) 1
Age-Specific Presentation
- Children 5-15 years: Most common age group for Strep A pharyngitis 1
- Children <3 years: Presents differently with fever, mucopurulent rhinitis, excoriated nares, and diffuse adenopathy; exudative pharyngitis is rare in this age group 1
Features Suggesting Viral Rather Than Strep A Infection
- Conjunctivitis
- Coryza (runny nose)
- Cough
- Diarrhea
- Hoarseness
- Discrete ulcerative stomatitis
- Viral exanthem 1
Diagnosis
When to Test
- Testing is recommended for children with clinical features suggesting bacterial pharyngitis
- Testing is not recommended when clinical features strongly suggest viral etiology 1
- Testing is generally not recommended in children younger than 3 years unless they have specific risk factors 1
Diagnostic Methods
- Rapid antigen detection test (RADT) - sensitivity 90-95% 2
- Throat culture (gold standard)
- A positive RADT is diagnostic for Strep A pharyngitis
- A backup culture should be performed in children and adolescents with negative RADT results 1
Treatment
First-Line Antibiotic Therapy
Penicillin or amoxicillin is the first-line treatment for Strep A pharyngitis due to their narrow spectrum of activity, infrequent adverse reactions, and modest cost. 2
Specific Regimens:
Oral penicillin V:
- Children: 250 mg two to three times daily for 10 days
- Adolescents: 250 mg four times daily or 500 mg twice daily for 10 days 2
Oral amoxicillin:
- 50 mg/kg once daily (maximum 1000 mg) or
- 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 2
Intramuscular benzathine penicillin G (single dose):
- Patients <27 kg: 600,000 U
- Patients ≥27 kg: 1,200,000 U 2
Alternative Treatments for Penicillin-Allergic Patients
- Clindamycin: 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days 2
- Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 2
- Clarithromycin: 7.5 mg/kg/dose twice daily (max 250 mg/dose) for 10 days 2
Treatment Duration
- A full 10-day course of antibiotics is essential for complete eradication of the organism from the pharynx and prevention of acute rheumatic fever 2
- Exception: Azithromycin is given for 5 days due to its prolonged tissue persistence 2
Symptomatic Relief
- Analgesics such as ibuprofen or acetaminophen for pain and fever 2
- Avoid aspirin in children due to risk of Reye syndrome 2
- Maintain adequate hydration 2
Important Considerations
Complications to Monitor
- Suppurative complications (rare): quinsy (peritonsillar abscess), acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis 1
- Non-suppurative complications (rare): acute rheumatic fever, acute glomerulonephritis 1
Follow-Up
- Follow-up post-treatment throat cultures or RADT are not routinely recommended 1
- Follow-up testing should be reserved for patients at high risk of acute rheumatic fever or those with recurrence of symptoms 1
Prevention and Control
- Hand hygiene
- Avoid close contact with infected individuals
- Do not share utensils or drinks 2
- Maintain isolation precautions for a minimum of 24 hours after starting effective antibiotic therapy 2
Special Situations
Asymptomatic Carriers
- Asymptomatic carriage of Strep A is frequent, especially in children
- Over 20% of asymptomatic school children may be carriers during winter and spring 1
- Testing or treatment of asymptomatic household contacts is not routinely recommended 1
Recurrent Infections
- Consider tonsillectomy for patients with ≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years 2
By following these guidelines for diagnosis and treatment, the risk of complications from Strep A infections can be minimized while ensuring appropriate antibiotic stewardship.