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Care Process Model
JANUARY
2014
DIAGNOSIS AND MANAGEMENT OF
Streptococcal Pharyngitis
This care process model (CPM) was developed by Intermountain Healthcare’s Antibiotic Stewardship team and
Primary Care Clinical Program. Based on expert opinion and the Infectious Disease Society of America IDSA
Clinical Practice Guidelines, it provides best-practice recommendations for diagnosis and management of
group A streptococcal pharyngitis (strep) including guidance for when and which antibiotics should be used.
KEY POINTS
• Accurate diagnosis can prevent serious complications. When strep is present, appropriate antibiotics can
prevent acute rheumatic fever, peritonsillar abscess, and other invasive infections. IDSA Treatment also prevents
spread of infection and improves clinical symptoms and signs for the patient.
GOALS
• Select appropriate antibiotics for patients
who meet the diagnostic criteria for a group A
strep throat infection.
• Reduce the unnecessary use of antibiotics
for an unclear diagnosis of strep and for
strep carriers.
• Differentiating between a patient with an active strep infection and a patient who is a strep carrier with
a viral illness (that prompts a strep culture) is challenging. Treating patients for active strep infection when
they are only carriers can result in overuse of antibiotics. Approximately 20% of asymptomatic school-aged children
may be strep carriers, and a throat culture during a viral illness may be positive but not need treatment. IDSA Prescribing
repeat antibiotics will not help these patients and can contribute to antibiotic resistance.
• For adult patients, routine overnight cultures after a negative rapid strep test are unnecessary in usual
circumstances because the risk for acute rheumatic fever is exceptionally low in adults. IDSA Physicians may continue
to use overnight throat cultures when the patient’s risk score is high or if the patient is at high risk due to contact or
employment (e.g., teachers, family member with strep, etc.).
Why Focus ON STREPTOCOCCAL PHARYNGITIS?
• Antibiotic prescribing for sore throat has dropped, but not enough. Only about 10% of patients seeking care for
sore throat have strep, but antibiotics are still prescribed about 60% of the time. Prescription rates dropped from 80%
to 70% around 1993 and to 60% around 2000, and have remained stable since then. JAMA
• Unnecessary antibiotic prescribing is costly and dangerous. From 1997 to 2010, the financial cost of unnecessary
antibiotic prescribing to adults with sore throat was about $500 million in the United States. Antibiotics can also
be expensive for patients and can have negative side effects. Between 5% and 25% of patients on antibiotics develop
diarrhea, and 1 in 1,000 visit an emergency department for a serious adverse drug event. JAMA
GermWatch is Intermountain’s source for up-to-date
information about infectious diseases currently circulating
in Utah communities.
For physicians: intermountainphysician.org/gw
For parents and patients: germwatch.org
The inside pages of this tool provide algorithms and associated notes for adult and pediatric patients, and can be folded open and posted in your
office or clinic. The back page summarizes identification and treatment of streptococcal pharyngitis carriers.
DIAGNOSIS AND MANAGEMENT OF
Streptococcal Pharyngitis – Pediatric
ALGORITHM: PEDIATRIC DIAGNOSIS AND TREATMENT
Recommend symptomatic
relief to all patients.
IMPORTANT:
Do not prescribe
antibiotics for strep
without a strep test.
TEST: Obtain rapid strep test (b)
(+)
(-)
TEST: Obtain
throat culture (c)
END.
(-)
Discontinue
antibiotic if
prescribed.
A
T
R
I
C
Signs and Symptoms of Streptococcal Pharyngitis (a)
Streptococcal pharyngitis
Viral pharyngitis
•• Sudden onset of sore throat
•• Age 5–15 years (most common)
•• Fever
•• Headache
•• Nausea, vomiting, abdominal pain
•• Tonsillopharyngeal inflammation
•• Patchy tonsillopharyngeal exudates
•• Palatal petechiae
•• Tender nodes
•• Winter and early spring presentation
•• History of exposure to
strep pharyngitis
•• Scarlatiniform rash
•• Edematous uvula
•• Conjunctivitis
•• Coryza
•• Cough
•• Diarrhea
•• Hoarseness
•• Discrete ulcerative
stomatitis
•• Viral exanthema
For a child under 3, obtain an RADT only when the
child has symptoms of strep/when the clinical picture is
strongly suggestive of strep.
• RADTs are highly specific; positive RADTs do not
necessitate a back-up culture.
• Testing is not recommended for patients with overt
viral features (see table above).IDSA
• Do not test asymptomatic contacts (e.g., close family).
• If a parent calls with a positive rapid strep from a takehome kit, confirm in the office with RADT before treating.
•
I
D
E
(a) Signs and symptoms of streptococcal and
viral pharyngitis. IDSA
(b) Rapid antigen detection test (RADT) notes.
(+)
P
NOTES
PRESCRIBE antibiotics
No penicillin allergy
Penicillin allergy
If the child can swallow pills:
<60 lbs (<27 kg):
•• Penicillin VK 250 mg orally twice daily for 10 days OR
•• Benzathine penicillin 600,000 IU IM x 1 dose
>60 lbs (>27 kg):
•• Penicillin VK 500 mg orally twice daily for 10 days OR
•• Benzathine penicillin 1,200,000 IU IM x 1 dose
•• Cephalexin 20 mg/kg twice daily (MAX 1,000 mg
daily) for 10 days OR
•• Azithromycin 12 mg/kg once daily (MAX 500 mg
daily) for 5 days OR
•• Clindamycin 7 mg/kg 3 times daily (MAX 900 mg
daily) for 10 days
If the child cannot swallow pills: Amoxicillin suspension
50 mg/kg once daily for 10 days (MAX 1,000 mg daily)
(c) Prescribing antibiotics before throat culture.
There may be compelling situations that will lead to a
24- to 48-hour prescription of antibiotics until the results
of the throat culture are available, but this is the exception.
(d) Follow-up.
•
•
If no improvement after 48 to 72 hours, reevaluate
patient for possible complications (peritonsillar
abscess, retropharyngeal abscess, etc.). (d)
Follow-up cultures are unnecessary to assess cure.
See back page for treatment of recurrent
streptococcal pharyngitis.
Intermountain measures the number
of strep diagnoses, RADTs, and
which antibiotics are prescribed.
DIAGNOSIS AND MANAGEMENT OF
ALGORITHM: ADULT DIAGNOSIS AND TREATMENT
Streptococcal Pharyngitis – Adult
ALGORITHM: ADULT DIAGNOSIS AND TREATMENT
Signs and Symptoms of Streptococcal Pharyngitis (a)
Recommend symptomatic
relief to all patients.
TEST: Obtain rapid strep test (b)
(-)
(+)
A
D
U
L
T
ASSESS risk of strep
Risk score: Assign 1 point for each of the following: NEJM
•• Fever >38°C
•• Absence of cough
•• Swollen, tender anterior cervical nodes
•• Tonsillar swelling or exudate
Other high-risk indicators: Contact or employment
(-)
risk (e.g., teachers family member
with strep, etc.)
IMPORTANT:
Do not prescribe
antibiotics for strep
without a strep test.
Low risk
(score <4 AND
no other high-risk
indicator)
High risk (score
≥4 OR high-risk
indicator)
TEST: Obtain
throat culture
NOTES
(a) Signs and symptoms of streptococcal and
viral pharyngitis. IDSA
Streptococcal pharyngitis
Viral pharyngitis
•• Sudden onset of sore throat
•• Fever
•• Headache
•• Nausea, vomiting, abdominal pain
•• Tonsillopharyngeal inflammation
•• Patchy tonsillopharyngeal exudates
•• Palatal petechiae
•• Tender nodes
•• Winter and early spring presentation
•• History of exposure to
strep pharyngitis
•• Scarlatiniform rash
•• Conjunctivitis
•• Coryza
•• Cough
•• Diarrhea
•• Hoarseness
•• Discrete ulcerative
stomatitis
•• Viral exanthema
(b) Rapid antigen detection test (RADT).
do not necessitate a
back-up culture for adults unless risk score is high or
the patient is at high risk due to contact or employment
(e.g., teachers, family member with strep, etc.).
• RADTs are highly specific and
• Testing is not recommended for patients with overt
viral features (see table above).IDSA
(-)
END.
(+)
throat culture is not
necessary in the case of a negative RADT in low-risk
patients because the low risk of acute rheumatic fever in
adults with acute pharyngitis. IDSA
• Do not test asymptomatic contacts (e.g., close family).
PRESCRIBE antibiotics
No penicillin allergy
Penicillin allergy
•• Penicillin V 250 mg orally 4 times daily or 500 mg 2
•• Clindamycin 300 mg 3 times daily for 10 days OR
times daily for 10 days OR
•• Amoxicillin 1,000 mg once daily or 500 mg twice daily
for 10 days
• In adults, a back-up
•• Cephalexin 500 mg twice daily for 10 days OR
• If
a patient calls with a positive rapid strep from a
take-home kit, confirm in the office with RADT
before treating.
(c) Follow-up cultures are unnecessary to assess cure.
•• Azithromycin 500 mg once daily for 5 days
If no improvement after 48 to 72 hours, reevaluate patient for possible
complications (peritonsillar abscess, retropharyngeal abscess, etc.). (c)
Intermountain measures the number
of strep diagnoses, RADTs, and
which antibiotics are prescribed.
Pharyngeal Carriers
Pharyngeal carriers are unlikely to spread streptococcal pharyngitis to close contacts, are at little or no risk of suppurative
or nonsuppurative complications, and usually don’t require antibiotic treatment. For these reasons, routine treatment of
strep carriers is not recommended. IDSA
• Reasons for recurrent streptococcal pharyngitis can include:
–– Chronic pharyngeal carriage masquerading as an acute strep infection due to a culture done during an intercurrent
viral infection
–– Noncompliance with prescribed antibiotic therapy
–– A new streptococcal pharyngitis infection
–– Recrudescence of infection with the original infecting strain (less common)
• Information to help determine if the positive culture is from a carrier state or an active infection:
Frequent recurrence (recurrent signs and symptoms within weeks or months of initial therapy with mostly viral
symptoms); presenting signs and symptoms; season of the year; patient age.
• Treatment:
–– When antibiotics might be needed. Carriers do not ordinarily require antibiotic therapy. Situations in which
antibiotic treatment may be indicated:
––
––
––
––
Community outbreak of acute rheumatic fever, acute poststreptococcal glomerulonephritis, or invasive
streptococcal pharyngitis
Outbreak of streptococcal pharyngitis in a closed or partially closed community
History of acute rheumatic fever (family or personal)
Tonsillectomy being considered only because of carriage
–– Criteria for tonsillectomy. ≥7 sore throat episodes in the past year OR ≥5 episodes in each of preceding 2 years OR
years. AAO
≥3 episodes in each of preceding 3
–– Definition of episode: Sore throat plus 1 of the following: Temperature >38.3°C, cervical lymphadenopathy
(tender lymph nodes or >2 cm), tonsillar exudate, positive culture for group A ß-hemolytic streptococcus
–– Treatment: Antibiotics administered in conventional dosage for proved or suspected streptococcal episodes
Antibiotics for Suspected Streptococcal Carrier IDSA
No penicillin allergy
Penicillin allergy
•• Penicillin V 50 mg/kg daily in 4 doses (MAX 2,000 mg daily*) for 10 days PLUS rifampin 20
•• Clindamycin 20–30 mg/kg daily
mg/kg daily in 1 dose (MAX 600 mg daily) for the last 4 days of treatment for 10 days
•• Amoxicillin-clavulanic 40 mg/kg daily in 3 doses for 10 days (MAX 2,000 mg daily*)
•• Benzathine penicillin G (intramuscular) 600,000 IU for <27 kg and 1,200,000 IU for ≥27
kg PLUS rifampin (oral) 20 mg/kg daily in 2 doses for 4 days (MAX 600 mg daily*)
References
AAO Baugh RF, Archer SM, Mitchell RB, et al; American Academy of
Otolaryngology-Head and Neck Surgery Foundation. Clinical practice
guideline: tonsillectomy in children. Otolaryngol Head Neck Surg.
2011;144(1 Suppl):S1-S30.
IDSA Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for
the diagnosis and management of group A streptococcal pharyngitis:
2012 update by the Infectious Diseases Society of America. Clin Infect
Dis. 2012;55(101):1279-1282.
JAMA Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat
in the United States, 1997-2010. JAMA Intern Med. 2013. doi: 10.1001/
jamainternmed.2013.11673
NEJM Wessels MR. Clinical practice. Streptococcal pharyngitis. N Engl J Med.
2011;364(7):648-655.
Intermountain patient tools
To order copies, go to i-printstore.com.
• Colds
and Coughs in Adults:
Managing Viral Infections
• Colds and Coughs in Children
and Adolescents: Managing
Viral Infections
• Viral Infection Rx
• Pediatric Dosing Guide:
Acetaminophen and Ibuprofen
Viral Infection
Name:
Date:
You have been diagnosed with an infection caused by a virus. Most colds, coughs, and sore throats
are caused by viruses. Fever is also a normal symptom of a viral infection. Antibiotics kill bacteria,
not viruses, and they will not help you feel better faster. Follow this prescription to feel better.
Diagnosis:
Cold/cough
Bronchitis
Sore throat
Other:
General Instructions:
 Get plenty of rest
 Drink plenty of fluid
 Use a humidifier or saline nasal spray to relieve congestion
 Stay away from smoke
 Other:
Medications:
 For pain:
 For cough:
 For other symptoms:
Follow-up:
 If you don’t improve in ______ days, if you have new symptoms, or if you have other
concerns, call or return to the office.
 If you received a SNAP (safety net antibiotic prescription), start taking it in ______ days
if you don’t improve or ______ days if you get worse. (Don’t fill the prescription until you
know you need it.)
 Other:
Doctor’s signature:
Date:
*50280*
Pt Inst 50280
© 2013 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CLD002 - 10/13
Intermountain provider tools
Available from the Primary Care Clinical Program page of
intermountain.net and intermountainphysician.org:
• Pediatric Strep Throat Flash Card
• Adult Strep Throat Flash Card
• Antibiotic Best Practices web page
Antibiotic Stewardship Team
in 3 doses (MAX 900 mg daily*)
for 10 days
*Prescribe MAX dose for adults.
•Sylvie Backman, MD
•Kim Brunisholz, MST
•Whitney Buckel, PharmD
•Wayne Cannon, MD
•Jenna DenBleyker, MD
•Missy Duke, PharmD
•Per Gesteland, MD
•Sharon Hamilton, MS, APRN
•Jeremy Meier, MD
•Jared Olson, PharmD
•Ken Schaecher, MD
•Douglas Smith, MD
•Eddie Stenehjem, MD
•Emily Thorell, MD
•Anthony Wallin, MD
•Matthew Walton, MD
This CPM is based on best evidence at the time of publication. It is not
meant to be a prescription for every patient. Clinical judgment based
on each patient’s unique situation remains vital.
©2014 Intermountain Healthcare. All rights reserved. Patient and Provider Publications 801-442-2963 CPM067 - 01/14
Not intended to replace physician judgment with respect to individual variations and needs.