What are the implications of recurrent Streptococcal (strep) infections?

From the Guidelines

For patients experiencing frequent strep infections, tonsillectomy may be considered as a definitive treatment, as recommended by the 2019 clinical practice guideline for tonsillectomy in children 1.

Management of Recurrent Strep Throat Infections

Recurrent strep throat infections can be challenging to manage, and the approach depends on the frequency and severity of the episodes.

• For patients with frequent strep infections (typically defined as 7 or more episodes in one year, 5 or more annually for two years, or 3 or more annually for three years), tonsillectomy may be considered as a definitive treatment.
• The decision to recommend tonsillectomy should be based on documentation of the frequency and clinical features of throat infection episodes, as well as shared decision-making with patients and families.
• For less severe recurrence patterns, antibiotic options include penicillin V, amoxicillin, or for penicillin-allergic patients, clindamycin or azithromycin.
• Completing the full antibiotic course is essential, even when symptoms improve, to prevent recurrence and reduce the risk of complications.
• Good hygiene practices like regular handwashing, avoiding sharing personal items, and replacing toothbrushes after infection can help prevent recurrence.

Antibiotic Treatment Options

The choice of antibiotic treatment depends on the patient's allergy status and the severity of the infection.

• Penicillin V (250-500 mg twice daily for 10 days) and amoxicillin (500 mg twice daily for 10 days) are commonly used antibiotics for strep throat.
• For penicillin-allergic patients, clindamycin (300 mg three times daily for 10 days) or azithromycin (500 mg on day 1, then 250 mg daily for 4 more days) may be used.
• The treatment regimens for chronic carriers of Group A Streptococci, as outlined in the 2012 clinical practice guideline for the diagnosis and management of Group A Streptococcal pharyngitis, include oral clindamycin, penicillin and rifampin, amoxicillin-clavulanic acid, and intramuscular and oral benzathine penicillin G 1.

Prevention of Recurrence

Preventing recurrence of strep throat infections is crucial to reduce the risk of complications and improve quality of life.

• Good hygiene practices, such as regular handwashing and avoiding sharing personal items, can help prevent the spread of the infection.
• Replacing toothbrushes after infection and avoiding close contact with individuals who have strep throat can also help prevent recurrence.
• In some cases, prophylactic antibiotics may be considered for patients with severe recurrence patterns, but this should be done under the guidance of a healthcare professional.

From the FDA Drug Label

In patients who are allergic to penicillin and sulfonamides, oral erythromycin is recommended by the American Heart Association in the long-term prophylaxis of streptococcal pharyngitis (for the prevention of recurrent attacks of rheumatic fever). Prevention of Recurrent Attacks of Rheumatic Fever Penicillin or sulfonamides are considered by the American Heart Association to be the drugs of choice in the prevention of recurrent attacks of rheumatic fever

Recurrent Strep Prevention:

• Penicillin is the first choice for prevention of recurrent attacks of rheumatic fever.
• Sulfonamides are the second choice for prevention of recurrent attacks of rheumatic fever.
• Erythromycin is recommended for patients who are allergic to penicillin and sulfonamides 2.

From the Research

Recurrent Strep Treatment Options

• Cephalosporins are useful for the treatment of recurrent streptococcal tonsillopharyngitis, as they have a lower rate of clinical failure compared to penicillins 3.
• Penicillin and amoxicillin are first-line antibiotics for the treatment of group A beta-hemolytic streptococcal pharyngitis, with a recommended course of 10 days 4.
• First-generation cephalosporins are recommended for patients with nonanaphylactic allergies to penicillin 4.
• Erythromycin is a traditional alternative to penicillins, but increased resistance and failure rates have been reported 3.

Diagnosis and Assessment

• The modified Centor score can be used to help physicians decide which patients need no testing, throat culture/rapid antigen detection testing, or empiric antibiotic therapy 5.
• Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly 5.
• Clinical decision rules, such as the presence of fever, tonsillar exudate, cervical lymphadenitis, and patient ages of 3 to 15 years, can increase clinical suspicion of group A beta-hemolytic streptococcal pharyngitis 4.

Antibiotic Comparisons

• Cephalosporins versus penicillin: low-certainty evidence suggests that cephalosporins may have a lower rate of clinical relapse, but the difference in symptom resolution is uncertain 6.
• Macrolides versus penicillin: low-certainty evidence suggests that there is no difference in symptom resolution or clinical relapse between macrolides and penicillin 6.
• Azithromycin versus amoxicillin: very low-certainty evidence suggests that azithromycin may have a higher rate of adverse events, but the difference in symptom resolution and clinical relapse is uncertain 6.
• Carbacephem versus penicillin: low-certainty evidence suggests that carbacephem may provide better symptom resolution post-treatment in adults and children 6.