Should a patient who completed treatment for streptococcal pharyngitis two weeks ago and now presents with a recurrent sore throat be retested for group A Streptococcus?

Recurrent Sore Throat After Treated Strep: Testing Approach

Yes, you should retest this patient with a throat culture or rapid antigen detection test (RADT) because they are now symptomatic again, and the guidelines explicitly state that testing is indicated for patients with recurrent symptoms after completing treatment. 1

Key Clinical Distinction: Symptomatic vs. Asymptomatic

The critical factor here is that your patient has symptoms (sore throat). The IDSA guidelines are clear on this point:

• Routine follow-up testing is NOT indicated for asymptomatic patients who completed a full course of therapy 1, 2
• Testing IS indicated when symptoms persist or recur after completing treatment 1, 3, 2

This patient falls into the second category—they are symptomatic with a new sore throat episode two weeks post-treatment.

Why Retesting Matters in This Scenario

Up to 20% of school-aged children are chronic GAS carriers during winter and spring, and this patient may be a carrier experiencing a concurrent viral infection rather than true streptococcal reinfection 1, 3, 2. The testing will help you distinguish between:

1. True GAS reinfection requiring alternative antibiotic therapy
2. Carrier state with viral pharyngitis requiring only symptomatic management
3. New viral pharyngitis in a previously treated patient

Clinical Assessment Before Testing

Look for features that suggest viral etiology (which would argue against GAS even if the test is positive in a carrier):

• Cough, rhinorrhea, hoarseness, or conjunctivitis strongly suggest viral infection 1, 3, 4
• Gradual onset rather than sudden onset 3
• Absence of fever or fever <100.4°F 1, 5

Look for features that suggest true GAS infection:

• Fever >100.4°F, tonsillar exudates, tender anterior cervical adenopathy 1, 3, 5
• Sudden onset of sore throat 1, 3
• Absence of viral symptoms 1, 3

Testing Approach

Perform throat culture or RADT to confirm the presence of GAS 1, 3. If using RADT in children/adolescents, confirm negative results with throat culture 1.

Management Based on Test Results

If Test is Positive AND Patient Has Classic Strep Symptoms:

Do NOT repeat the same antibiotic. The patient needs alternative therapy with superior eradication rates 1, 3, 6:

First-line choice: Clindamycin

• Adults: 300 mg orally three times daily for 10 days 3, 6
• Children: 7 mg/kg per dose three times daily (max 300 mg/dose) for 10 days 1, 3
• This is the most effective option for eradication, especially in carriers who failed penicillin 3, 6

Alternative regimens:

• Amoxicillin-clavulanate: 40 mg/kg/day (of amoxicillin component) divided three times daily for 10 days 1, 3, 6
• First-generation cephalosporin (e.g., cephalexin): 20 mg/kg twice daily (max 500 mg/dose) for 10 days 1, 3

If Test is Positive BUT Patient Has Viral Symptoms:

This suggests carrier state with concurrent viral infection. In this scenario:

• Antibiotics are generally NOT recommended unless special circumstances exist 1, 3
• Provide symptomatic management only 3, 2

Special circumstances requiring treatment despite likely carrier state:

• Personal or family history of rheumatic fever 1, 3, 6
• Community outbreak of acute rheumatic fever or invasive GAS 1, 3, 6
• Outbreak in closed/semi-closed community 1, 3, 6
• Excessive family anxiety about GAS infections 1, 3

If Test is Negative:

No antibiotic therapy is needed. Provide symptomatic management with analgesics/antipyretics 1, 2.

Common Pitfalls to Avoid

• Do not perform routine testing on asymptomatic patients after treatment—this leads to unnecessary retreatment of carriers 1, 2
• Do not repeat the same beta-lactam antibiotic (amoxicillin or penicillin) for symptomatic recurrence—it is ineffective 3, 6, 2
• Do not assume every positive test in a recurrent case requires antibiotics—consider the clinical picture and whether viral symptoms predominate 1, 3, 2
• Do not routinely test or treat household contacts after a single recurrence 1, 3, 6

When to Consider Household Contact Testing

Only consider simultaneous testing and treatment of all family members if there are multiple repeated episodes over several months suggesting "ping-pong" transmission 1, 3.