Should an elderly patient with 2 weeks of burning throat pain undergo a strep (streptococcal) test?

No, an elderly patient with 2 weeks of burning throat pain should NOT undergo routine strep testing

Group A streptococcal pharyngitis is extremely unlikely after 2 weeks of symptoms, and testing in this scenario would likely identify asymptomatic carriers rather than acute infection, leading to unnecessary antibiotic treatment. 1

Why Testing is Not Indicated

Duration of Symptoms Rules Out Acute GAS Pharyngitis

• Acute streptococcal pharyngitis is a self-limited illness that typically resolves within 3-5 days without intervention 2
• The 2-week duration of symptoms strongly suggests a non-streptococcal etiology (viral, irritant, reflux, or other chronic condition) 1
• Neither throat culture nor rapid antigen detection tests (RADTs) can accurately differentiate acutely infected persons from asymptomatic streptococcal carriers with intercurrent viral or other pharyngitis 1

Low Pre-Test Probability in Elderly Adults

• GAS causes only 5-15% of acute pharyngitis cases in adults, and the risk of acute rheumatic fever is extremely low in elderly patients even with untreated streptococcal pharyngitis 1
• The elderly population has minimal risk of nonsuppurative complications (acute rheumatic fever), which is the primary rationale for treating GAS pharyngitis 1
• Testing should be reserved for patients with clinical features suggestive of acute GAS infection, not chronic symptoms 1

Clinical Features That Would Argue Against GAS

• "Burning" throat pain lasting 2 weeks is atypical for acute streptococcal pharyngitis 3
• Classic GAS pharyngitis presents with sudden onset of fever, tonsillar exudate, cervical lymphadenopathy, and absence of cough 3, 4
• The prolonged burning quality suggests alternative diagnoses such as gastroesophageal reflux, chronic irritation, or persistent viral infection 1

What Should Be Done Instead

Evaluate for Alternative Diagnoses

• Consider gastroesophageal reflux disease (GERD), chronic irritant exposure, allergic pharyngitis, or persistent viral infection 1
• Assess for red flag symptoms requiring urgent evaluation (dysphagia, odynophagia, weight loss, unilateral symptoms suggesting abscess or malignancy)
• Review medication history for drug-induced causes

Symptomatic Management

• Acetaminophen or NSAIDs (like ibuprofen) are recommended first-line agents for moderate to severe sore throat symptoms 2
• Avoid aspirin in any patient with potential viral illness due to Reye syndrome risk 2

Critical Pitfall to Avoid

• Testing patients with prolonged symptoms (>1 week) will likely identify asymptomatic GAS carriers (approximately 25% of the population) rather than acute infection, leading to unnecessary antibiotic prescriptions 1
• This contributes to antimicrobial resistance without clinical benefit, as up to 70% of patients with sore throats receive antibiotics when only 20-30% have GAS pharyngitis 1
• Antimicrobial therapy should be prescribed only for proven episodes of acute GAS pharyngitis, not for carrier states 1

When GAS Testing Would Be Appropriate in Adults

• Acute onset (typically <3-5 days) of pharyngitis with fever, tonsillar exudate, and cervical lymphadenopathy 3, 4
• Absence of viral symptoms (cough, rhinorrhea, hoarseness, oral ulcers) 1
• Known exposure to confirmed GAS case (particularly household contact with school-age children) 1
• Even then, clinical algorithms without microbiological confirmation are considered acceptable in adults given the low risk of rheumatic fever 1