What is the treatment for a strep-positive individual without symptoms?

Management of Strep-Positive Individuals Without Symptoms

Asymptomatic individuals who test positive for group A streptococci do not require antibiotic treatment as they are likely carriers who are at low risk for developing complications and are unlikely to spread the organism to close contacts. 1

Understanding Streptococcal Carriers

• Streptococcal carriers have group A β-hemolytic streptococci present in their pharynx but show no evidence of immunologic response to the organism 1
• During winter and spring in temperate climates, up to 20% of asymptomatic school-aged children may be streptococcal carriers 1, 2
• Carriers are at low risk, if any, for developing suppurative complications (e.g., peritonsillar abscess) or nonsuppurative complications (e.g., acute rheumatic fever) 1
• Carriers are unlikely to spread the organism to their close contacts 1, 2

Rationale for Not Treating Asymptomatic Carriers

• It is more difficult to eradicate group A streptococci from the upper respiratory tracts of streptococcal carriers compared to those with acute infection 1
• Many published studies showing high rates of failure to eradicate group A streptococci with penicillin therapy likely included carriers 1
• The Infectious Diseases Society of America (IDSA) guidelines clearly state that routine culture or treatment of asymptomatic individuals is not recommended 1, 2
• Follow-up throat cultures are not routinely indicated for asymptomatic patients who have received a complete course of therapy for group A streptococcal pharyngitis 1

Special Circumstances When Treatment May Be Considered

Treatment of asymptomatic carriers may be considered in specific situations:

• During a community outbreak of acute rheumatic fever, acute poststreptococcal glomerulonephritis, or invasive GAS infection 1
• During an outbreak of GAS pharyngitis in a closed or partially closed community 1
• In the presence of a family or personal history of acute rheumatic fever 1
• In a family with excessive anxiety about GAS infections 1
• When tonsillectomy is being considered only because of carriage 1

Treatment Regimens for Carriers When Indicated

When treatment of carriers is deemed necessary, the following regimens have been shown to be more effective than penicillin or amoxicillin:

• Oral clindamycin: 20–30 mg/kg/day in 3 doses (max = 300 mg/dose) for 10 days 1
• Penicillin V with rifampin: Penicillin V for 10 days plus rifampin for the last 4 days of treatment 1
• Amoxicillin–clavulanic acid: 40 mg amoxicillin/kg/day in 3 doses for 10 days 1
• Intramuscular benzathine penicillin G with oral rifampin: One dose of benzathine penicillin G plus rifampin for 4 days 1

Distinguishing Carriers from Acute Infection

• Helpful clues to differentiate carriers with intercurrent viral infections from patients with acute streptococcal pharyngitis include:
  • Patient's age 1
  • Season of the year 1
  • Local epidemiology (e.g., presence of influenza or enteroviral illnesses) 1
  • Precise nature of presenting signs and symptoms 1

Common Pitfalls

• Treating all strep-positive individuals regardless of symptoms can lead to unnecessary antibiotic use, contributing to antimicrobial resistance 1, 2
• Treating carriers may not eradicate the organism and can give false reassurance 1
• Attempting to eradicate carriage through repeated courses of antibiotics is generally unsuccessful and not recommended 1
• Misinterpreting a positive test in an asymptomatic individual as requiring treatment, when they are likely just carriers 2