What is the follow-up for Group A streptococcal (GAS) tonsillopharyngitis in children and adolescents?

From the Guidelines

Follow-up for group A streptococcal tonsillopharyngitis in children and adolescents should occur 2-7 days after diagnosis if symptoms persist or worsen, though routine post-treatment throat cultures are not recommended for asymptomatic patients. The standard treatment is penicillin V (250 mg twice daily for children <27 kg, 500 mg twice daily for larger children and adolescents) for 10 days, as recommended by the Infectious Diseases Society of America 1. Amoxicillin (50 mg/kg once daily, maximum 1000 mg) for 10 days is an alternative with better palatability. For penicillin-allergic patients, first-generation cephalosporins can be used if the allergy is non-anaphylactic, while macrolides like azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days) are options for those with severe penicillin allergy, as suggested by the American Heart Association 1. Patients can return to school or daycare 24 hours after starting antibiotics when they're fever-free. Complications requiring immediate attention include peritonsillar abscess (severe throat pain, difficulty opening mouth, "hot potato" voice), rheumatic fever (joint pain, rash, carditis), and post-streptococcal glomerulonephritis (dark urine, facial edema). Complete antibiotic courses are essential even if symptoms resolve quickly to prevent complications and recurrence, as emphasized by the Infectious Diseases Society of America 1 and the American Heart Association 1.

Some key points to consider in the management of group A streptococcal tonsillopharyngitis include:

• The importance of accurate diagnosis, which can be achieved through a combination of clinical judgment and diagnostic test results, such as throat culture or rapid antigen detection test (RADT) 1.
• The need for adequate antibiotic treatment to prevent complications, such as rheumatic fever and post-streptococcal glomerulonephritis 1.
• The choice of antibiotic, which should be based on factors such as the patient's age, weight, and allergy history, as well as the severity of the infection 1.
• The importance of completing the full course of antibiotic treatment, even if symptoms resolve quickly, to ensure that the infection is fully cleared and to prevent recurrence 1.

Overall, the management of group A streptococcal tonsillopharyngitis requires a careful and individualized approach, taking into account the patient's specific needs and circumstances, as well as the latest evidence-based guidelines and recommendations from reputable organizations such as the Infectious Diseases Society of America and the American Heart Association 1.

From the FDA Drug Label

It is recommended that there be at least 10 days’ treatment for any infection caused by Streptococcus pyogenes to prevent the occurrence of acute rheumatic fever. Treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic, or evidence of bacterial eradication has been obtained

The recommended treatment duration for Group A streptococcal tonsillopharyngitis in children and adolescents is at least 10 days to prevent the occurrence of acute rheumatic fever.

• The treatment should be continued for a minimum of 48 to 72 hours beyond the time that the patient becomes asymptomatic, or evidence of bacterial eradication has been obtained 2 2.

From the Research

Group A Streptococcal Tonsillopharyngitis in Children and Adolescents

• The treatment of group A streptococcal tonsillopharyngitis in children and adolescents is crucial to prevent complications such as rheumatic fever and post-streptococcal glomerulonephritis 3, 4, 5, 6, 7.
• A 5-day course of cefuroxime axetil was found to be at least as effective as a 10-day course of penicillin V in treating group A streptococcal tonsillopharyngitis in children and adolescents, with a bacteriological eradication rate of 90.52% and 89.53% in children aged 1-5 years and 6-17 years, respectively 3.
• Clarithromycin, a macrolide antibiotic, was found to have a lower bacteriological eradication rate compared to amoxicillin/clavulanate and penicillin V, especially in areas with high resistance rates 4.
• Penicillin has been the traditional treatment of choice for group A streptococcal tonsillopharyngitis, but its effectiveness has been questioned due to increasing resistance rates and poor patient compliance 5.
• A meta-analysis of short-course antibiotic treatment for group A streptococcal tonsillopharyngitis found that cephalosporins had superior bacterial cure rates compared to 10-day penicillin treatment, while macrolides had similar cure rates to 10-day comparators 7.
• The choice of antibiotic treatment for group A streptococcal tonsillopharyngitis should be based on factors such as patient age, antibiotic resistance patterns, and patient compliance, with penicillin still being a recommended first-line treatment due to its low cost and lack of resistance 6.

Treatment Options

• Cefuroxime axetil: a 5-day course was found to be effective in treating group A streptococcal tonsillopharyngitis in children and adolescents 3.
• Penicillin V: a 10-day course is traditionally recommended, but its effectiveness has been questioned due to increasing resistance rates and poor patient compliance 5.
• Clarithromycin: a 5-day course was found to have a lower bacteriological eradication rate compared to amoxicillin/clavulanate and penicillin V, especially in areas with high resistance rates 4.
• Amoxicillin/clavulanate: a 5-day course was found to have similar clinical efficacy to 10-day penicillin V treatment, but with a higher bacteriological eradication rate 4.

Complications and Prevention

• Rheumatic fever and post-streptococcal glomerulonephritis are potential complications of untreated or inadequately treated group A streptococcal tonsillopharyngitis 3, 5.
• Prompt and effective treatment with antibiotics can prevent these complications, emphasizing the importance of accurate diagnosis and appropriate treatment 6.