Patient Education and Treatment for Streptococcal Carriers
Streptococcal carriers do not ordinarily require antimicrobial therapy as they are at low risk for developing complications and are unlikely to spread the organism to close contacts. 1
What is a Streptococcal Carrier?
- A streptococcal carrier has Group A Streptococcus (GAS) present in their throat but shows no evidence of an active immunologic response to the organism 1
- Up to 20% of asymptomatic school-aged children may be GAS carriers during winter and spring in temperate climates 2
- Carriers may be colonized by GAS for 6 months or longer without developing symptoms 2
- It is often difficult to differentiate a carrier with an intercurrent viral infection from a patient with acute streptococcal pharyngitis 1
Health Implications for Carriers
- Carriers are unlikely to spread the organism to their close contacts 1, 2
- They are at very low risk for developing suppurative complications (like abscess) or nonsuppurative complications (like acute rheumatic fever) 1, 2
- It is more difficult to eradicate GAS from the upper respiratory tracts of carriers compared to those with acute infections 1
When Treatment is NOT Needed
- Routine testing or treatment is not recommended for asymptomatic carriers 1
- Routine post-treatment testing is not recommended for asymptomatic patients who have completed a full course of therapy for strep throat 3
- Household contacts of patients with GAS pharyngitis do not require routine testing or treatment 1
Special Situations When Treatment IS Recommended
Treatment of carriers may be considered in these specific circumstances:
- During a community outbreak of acute rheumatic fever, acute post-streptococcal 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
- When "Ping-Pong" spread of GAS has been occurring within a family 1
Recommended Treatment Regimens for Carriers
When treatment is indicated, the following options are more effective than penicillin or amoxicillin for eliminating the carrier state:
| Medication | Dosage | Duration |
|---|---|---|
| Oral Clindamycin | 20–30 mg/kg/day in 3 doses (max = 300 mg/dose) | 10 days |
| Penicillin V with Rifampin | Penicillin V: 50 mg/kg/day in 4 doses (max = 2000 mg/day) Rifampin: 20 mg/kg/day in 1 dose for last 4 days (max = 600 mg/day) |
10 days |
| Amoxicillin–clavulanic acid | 40 mg amoxicillin/kg/day in 3 doses (max = 2000 mg amoxicillin/day) | 10 days |
| Benzathine penicillin G with Rifampin | Benzathine penicillin G: 600,000 U for <27 kg and 1,200,000 U for ≥27 kg Rifampin: 20 mg/kg/day in 2 doses (max = 600 mg/day) |
Penicillin: 1 dose Rifampin: 4 days |
Common Clinical Scenarios and Management
- If symptoms persist or recur after completing antibiotic treatment, a follow-up throat culture should be performed 3
- For patients with multiple episodes of GAS pharyngitis within a short period, consider testing family members and treating those with positive cultures 3
- When distinguishing between carrier state and acute infection, consider the patient's age, season, local epidemiology, and specific symptoms 1
Important Patient Education Points
- Carriers should understand they are at low risk for complications 1
- Completing the full course of antibiotics (when prescribed) is essential to prevent treatment failure 4, 5
- Skipping doses or not completing the full course of therapy may decrease treatment effectiveness and increase antibiotic resistance 4
- Penicillin treatment for strep throat should be continued for 10 days to optimize cure 6
- Patients should be informed that diarrhea is a common side effect of antibiotics 4
Common Pitfalls to Avoid
- Unnecessarily treating asymptomatic carriers 3
- Interpreting a positive test after treatment as treatment failure when it may represent the carrier state 3
- Using inappropriate antibiotics such as tetracyclines or sulfonamides which are not effective against GAS 3
- Failing to distinguish between persistent carriage with intercurrent viral infection and true streptococcal pharyngitis 1