What is the recommended management for scarlet fever?

Scarlet Fever Management

First-Line Antibiotic Treatment

Oral Penicillin V (phenoxymethylpenicillin) 250-500 mg every 6-8 hours for 10 days is the recommended first-line treatment for scarlet fever, and antibiotics should be started immediately upon clinical diagnosis to reduce complications and transmission. 1, 2

• The 10-day course is critical to prevent acute rheumatic fever, regardless of symptom resolution 1, 2, 3
• Alternative dosing of 500 mg twice daily or 250 mg three times daily is also acceptable 1
• Patients become non-contagious after 24 hours of antibiotic therapy 1

Alternative Antibiotic Regimens

For patients with penicillin allergy:

• First-generation cephalosporins are preferred for patients without immediate hypersensitivity to β-lactam antibiotics 1
• Macrolides (such as azithromycin or clarithromycin) should be used only for patients with true penicillin allergy, with awareness that some Streptococcus pyogenes strains may be macrolide-resistant 1
• Amoxicillin 500 mg every 12 hours or 250 mg every 8 hours for 10 days is an alternative option 3

Critical caveat: Never use sulfonamide antibiotics, as they are associated with increased disease severity and mortality in streptococcal infections 1

Timing and Initiation of Treatment

• Antibiotics can be started up to 9 days after symptom onset and still prevent rheumatic fever 1
• Early treatment reduces the infectivity period and morbidity 1
• Treatment should be initiated immediately based on clinical presentation without waiting for laboratory confirmation in typical cases 4

Diagnostic Confirmation

While treatment should not be delayed, diagnostic confirmation is recommended:

• Throat culture or rapid antigen detection test (RADT) should be obtained to confirm Group A Streptococcus infection 1
• Throat culture remains the reference standard, with specimens obtained from the posterior pharynx and tonsillar surfaces 1
• Proper swabbing technique involves bilateral sampling of the posterior pharynx and tonsillar surfaces 1

Symptomatic Management

• Antipyretics may be used for fever relief but do not replace antibiotics 1
• Never use aspirin in children under 16 years due to risk of Reye's syndrome 1
• Antibiotics should be taken at the start of a meal to minimize gastrointestinal intolerance 3

Monitoring and Follow-Up

• Monitor for clinical improvement within 48-72 hours of starting antibiotics 1
• If symptoms persist beyond 3-5 days of antibiotic therapy, reassess the diagnosis and consider alternative pathogens 1
• Clinical follow-up is recommended to ensure symptom resolution 1
• Post-treatment throat cultures are not routinely recommended unless symptoms persist or recur 1

Management of Close Contacts

• Routine throat cultures or treatment for asymptomatic household contacts is generally not necessary 1
• In outbreak situations, throat cultures should be performed for all patients, and only those with positive cultures should be treated 1

Infection Control Measures

For hospitalized patients or healthcare settings:

• Patients should be isolated for a minimum of 24 hours of effective antibiotic therapy 5
• Healthcare workers must use disposable gloves and aprons when in contact with the patient 5
• Strict hand hygiene with soap and water or alcohol hand rub before and after patient contact is mandatory 5

Key Clinical Features to Recognize

• Fever ≥38°C (102°F) persisting for at least 5 days 1
• Distinctive sandpaper-like macro-papular rash beginning on trunk and spreading to extremities with accentuation in the perineal region 1, 4
• Sore throat with characteristic oral changes including "strawberry tongue" or "raspberry tongue" 6
• The rash appears earlier in illness and rarely becomes petechial 1