What are the potential complications and management strategies for patients with strep infections, especially those with a history of recurrent infections or underlying medical conditions?

Complications of Streptococcal Infections

Group A streptococcal pharyngitis complications are generally rare in both children and adults, but include suppurative complications (quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis) and non-suppurative complications (acute rheumatic fever, acute glomerulonephritis), with prevention of acute rheumatic fever being the primary reason for antibiotic treatment. 1

Non-Suppurative Complications

Acute Rheumatic Fever

• Acute rheumatic fever incidence is very low in Europe, but prevention depends on effective control of group A streptococcal pharyngitis 1
• Particularly important for high-risk patients, especially those with prior rheumatic fever history 1
• Treatment must be sufficient to eliminate the organism with a minimum 10-day course to prevent acute rheumatic fever 2
• Patients with history of acute rheumatic fever are at very high risk of recurrences after subsequent group A streptococcal pharyngitis and require continuous antimicrobial prophylaxis 3

Acute Glomerulonephritis

• Rare consequence following group A streptococcal pharyngitis after a latency period of a few weeks 1
• Can also occur following group C or G streptococcal infections, though causal relationship not clearly established 1

Suppurative Complications

Common Suppurative Complications

• Quinsy (peritonsillar abscess) occurs mainly in young adults as a polymicrobial infection, with group A streptococcus as the main organism 1
• Male patients aged 21-40 years who smoke are significantly more likely to develop peritonsillar abscess after initial presentation of uncomplicated sore throat 1
• Other suppurative complications include acute otitis media, cervical lymphadenitis, mastoiditis, and acute sinusitis 1

Risk Groups Requiring Special Attention

High-Risk Populations

• Subjects at increased risk of complications include those with: 1
  • Increased risk of severe infections
  • Risk of immunosuppression
  • History of valvular heart disease
  • History of rheumatic fever

Pharyngeal Carriers

• Streptococcal carriers show extremely low risk of post-streptococcal complications and their likelihood of transmitting infection is small 1
• Carriers are at low risk, if any, for developing suppurative or nonsuppurative complications including acute rheumatic fever 1
• Up to 20% of asymptomatic school-aged children may be streptococcal carriers during winter and spring 1

Management Strategies for Recurrent Infections

Distinguishing True Infection from Carriage

• Helpful clues include patient's age, season, local epidemiology (presence of influenza or enteroviral illnesses), and precise nature of presenting signs and symptoms 1
• Clinical response to antibiotic therapy and presence/absence of group A streptococci during asymptomatic intervals helps distinguish persistent carriage from repeated episodes 1

Treatment Approach for Recurrences

• For single episodes of symptomatic, culture-confirmed or RADT-confirmed group A streptococcal pharyngitis occurring shortly after completing therapy, any standard agent is appropriate 1
• Consider intramuscular benzathine penicillin G due to compliance issues 1
• For multiple recurrent episodes, specialized regimens with higher eradication rates should be used 1

Household Contact Management

• Routine throat cultures or treatment for household contacts is not necessary except in specific situations with increased risk of frequent infections or non-suppurative sequelae 1
• Approximately 25% of household contacts may harbor group A streptococci asymptomatically 1
• When "ping-pong" spread is suspected with multiple family members having symptomatic episodes, perform simultaneous cultures for all family contacts and treat those who are positive 1

Role of Tonsillectomy

• Continuous antimicrobial prophylaxis is not recommended except for preventing recurrences of acute rheumatic fever 1
• Tonsillectomy may be considered for rare patients whose symptomatic episodes do not diminish in frequency over time with no alternative explanation for recurrent pharyngitis 1
• Tonsillectomy may decrease recurrences but only for a limited period 1

Complications from Group C and G Streptococci

Clinical Presentation

• Cases of severe or recurrent pharyngitis due to group C streptococci have been reported 1
• Patients with group C streptococci may have exudative tonsillitis and anterior cervical adenopathy more frequently 1

Uncommon Complications

• Reported complications include reactive arthritis, subdural empyema, and acute glomerulonephritis, though causal relationship not clearly established 1
• Group C and G septicemia has been documented over extended periods 1

Critical Pitfalls to Avoid

• Do not treat asymptomatic carriers with repeated courses of antibiotics, as they are at very low risk for complications and eradication is difficult 1
• Do not routinely culture or treat asymptomatic household contacts unless special circumstances exist 1
• Ensure minimum 10-day treatment for any group A streptococcal infection to prevent acute rheumatic fever 2, 4
• Do not rely on oral route in patients with severe illness, nausea, vomiting, or intestinal hypermotility 4