What is the recommended assessment and treatment plan for a patient presenting with symptoms of strep throat?

Assessment for Strep Throat - SOAP Note

Subjective

Key Historical Features to Document:

• Duration of symptoms (pharyngitis typically <14 days) 1
• Fever history (≥38.0°C suggests bacterial etiology) 2
• Absence of viral features: specifically ask about cough, rhinorrhea, hoarseness, and oral ulcers—their presence strongly suggests viral pharyngitis and testing is NOT recommended 1
• Age of patient: children <3 years rarely need testing unless high-risk factors present (e.g., older sibling with GAS) 1
• Exposure history: contact with confirmed strep cases 1
• Symptom severity: odynophagia, difficulty swallowing, neck swelling 3

Common Pitfall: Do not test or treat patients with clear viral features (cough, rhinorrhea, hoarseness, oral ulcers) as this leads to antibiotic overuse 1.

Objective

Physical Examination Findings to Document:

• Tonsillar exudate (increases likelihood of GAS) 2
• Anterior cervical lymphadenopathy (palpable, tender nodes) 2
• Pharyngeal erythema and tonsillar enlargement 3
• Absence of viral signs: no conjunctivitis, no discrete oral ulcers, no rhinorrhea 1

Diagnostic Testing Algorithm:

For Children and Adolescents:

• Perform rapid antigen detection test (RADT) if clinical features suggest bacterial pharyngitis 1
• If RADT is positive: treat immediately, no backup culture needed (specificity 96%) 1, 2
• If RADT is negative: MUST perform backup throat culture due to test sensitivity of only 65-75% 1, 2
• Do NOT test children <3 years unless high-risk factors present 1

For Adults:

• Perform RADT if clinical features suggest bacterial pharyngitis 1
• If RADT is positive: treat immediately 1
• If RADT is negative: backup culture is NOT routinely necessary due to low GAS incidence and extremely low rheumatic fever risk in adults 1
• Exception: physicians seeking maximal sensitivity may back up negative RADTs with culture 1

Critical Testing Technique: Swab both posterior pharyngeal wall AND tonsils vigorously for maximum yield 4. Poor technique is a major cause of false negatives 5.

Assessment

Diagnosis Documentation:

• Group A Streptococcal Pharyngitis (if RADT or culture positive) 1
• Acute Pharyngitis, likely viral (if testing negative or viral features present) 4

Do NOT use:

• Anti-streptolysin-O (ASO) or anti-DNAase B titers for acute diagnosis—these reflect past, not current infection 1
• Clinical features alone to diagnose—they cannot reliably discriminate GAS from viral pharyngitis 1

Plan

If GAS Pharyngitis Confirmed:

First-Line Antibiotic Treatment (Non-Penicillin Allergic):

Penicillin or amoxicillin is the drug of choice based on narrow spectrum, proven efficacy, safety, and low cost 1. Penicillin-resistant GAS has never been documented 1.

Specific Dosing:

• Amoxicillin: 500 mg every 12 hours OR 250 mg every 8 hours for mild/moderate; 875 mg every 12 hours OR 500 mg every 8 hours for severe infections 6
• Children >3 months: 25 mg/kg/day divided every 12 hours OR 20 mg/kg/day divided every 8 hours for mild/moderate; 45 mg/kg/day divided every 12 hours OR 40 mg/kg/day divided every 8 hours for severe 6
• Duration: 10 days minimum to prevent acute rheumatic fever 1, 6, 7

Penicillin-Allergic Patients:

• First-generation cephalosporin (if no anaphylactic sensitivity) for 10 days 1
• Clindamycin for 10 days 1
• Clarithromycin for 10 days 1
• Azithromycin for 5 days 1

Important Caveat: Consider macrolide resistance if patient has had multiple macrolide courses 8.

Adjunctive Therapy:

• Acetaminophen or NSAIDs for moderate to severe symptoms or high fever 1
• Avoid aspirin in children 1
• Do NOT use corticosteroids 1

If Testing Negative:

Withhold or discontinue antibiotics 4. Most cases are viral and self-limited 1, 4.

Symptomatic Treatment Only:

• Ibuprofen or acetaminophen for pain relief 4
• Reassurance about self-limited nature 1

Follow-Up:

Do NOT perform routine post-treatment cultures or RADT in asymptomatic patients who completed therapy 1, 8. This is a key quality indicator 4.

Post-treatment testing only indicated for:

• Patients with persistent or recurrent symptoms 8
• History of rheumatic fever 8
• Outbreaks of acute rheumatic fever or post-streptococcal glomerulonephritis 8

If Symptoms Persist After Treatment:

• Consider treatment failure, poor compliance, new infection with different strain, carrier state with viral infection, or macrolide resistance 8
• Retreat with alternative antibiotic: clindamycin, narrow-spectrum cephalosporin, or amoxicillin-clavulanate 8
• Perform follow-up throat culture 8

Do NOT test or treat asymptomatic household contacts routinely 1. Up to 25% may be carriers, but prophylaxis is not effective and risks antibiotic adverse effects 1.

Patient Education:

• Complete full 10-day course even if feeling better 7
• Skipping doses increases resistance risk 7
• Return if symptoms worsen or persist beyond 48-72 hours of treatment 1
• Contagious period ends 24 hours after starting antibiotics 1