How should I treat 2 patients with sore throats and negative rapid strep (streptococcal) tests, whose symptoms started 3 days ago, after close contact with individuals who have tested positive for strep throat?

Management of Patients with Sore Throat and Negative Rapid Strep Tests After Exposure to Strep-Positive Individuals

For patients with sore throats and negative rapid strep tests who had close contact with strep-positive individuals, symptomatic treatment with analgesics is recommended without antibiotic therapy, as negative rapid antigen detection tests do not require antibiotic treatment in the absence of high clinical suspicion. 1

Clinical Assessment

• The Centor clinical scoring system can help identify patients with higher likelihood of group A streptococcal infection, considering factors such as fever, absence of cough, tonsillar exudates, and tender anterior cervical lymphadenopathy 1
• In this case, patients have only sore throat without other symptoms, suggesting a lower Centor score (likely 0-2), which indicates low probability of streptococcal infection 1
• Despite the exposure history to strep-positive children, the negative rapid strep test results are reliable enough to guide management 1

Interpretation of Negative Rapid Tests

• If rapid antigen detection tests (RADTs) are performed, throat culture is not necessary after a negative RADT for the diagnosis of group A streptococci in both children and adults 1
• The specificity of most RADTs is excellent (≥95%) compared with blood agar plate culture, meaning false-positive results are unusual 1
• While sensitivity of most RADTs is between 80-90%, the negative predictive value is high enough that confirmation with throat culture is not always necessary, especially in adults with low clinical suspicion 1

Treatment Recommendations

• Antibiotics should not be used in patients with less severe presentation of sore throat (0-2 Centor criteria) to relieve symptoms 1
• For symptomatic relief, either ibuprofen or paracetamol (acetaminophen) is recommended 1
• Sore throat should not be treated with antibiotics to prevent complications in low-risk patients with no previous history of rheumatic fever 1
• The modest benefits of antibiotics have to be weighed against side effects, impact on microbiota, increased antimicrobial resistance, and costs 1

Special Considerations

• Despite the exposure to strep-positive children, the negative rapid tests and minimal symptoms (only sore throat) do not warrant antibiotic therapy 1
• Group C streptococcus can occasionally cause pharyngitis and would not be detected by rapid tests specific for group A streptococcus, but this is less common and typically presents with more severe symptoms 2
• If symptoms worsen significantly or persist beyond 5-7 days, reassessment may be warranted 2

Common Pitfalls to Avoid

• Prescribing antibiotics despite negative rapid tests and minimal symptoms leads to unnecessary antibiotic use and potential side effects 3
• Assuming that exposure history alone warrants treatment despite negative testing and minimal symptoms 1
• Failing to provide adequate symptomatic relief, which is the mainstay of treatment for viral pharyngitis 1
• Requesting unnecessary additional testing (such as throat cultures or biomarkers) when rapid tests are negative in low-risk patients 1

By following these evidence-based recommendations, you can provide appropriate care while avoiding unnecessary antibiotic use, which helps prevent antimicrobial resistance and adverse effects.