Executive Summary: Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America

IDSA GUIDELINES Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America Stanford T. Shulman,1 Alan L. Bisno,2 Herbert W. Clegg,3 Michael A. Gerber,4 Edward L. Kaplan,5 Grace Lee,6 Judith M. Martin,7 and Chris Van Beneden8 1 Department of Pediatrics, Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois; 2Department of Medicine, University of Miami Miller School of Medicine, Miami Veterans Affairs Healthcare System, Miami, Florida; 3Department of Pediatrics, Hemby Children’s Hospital and Eastover Pediatrics, Charlotte, North Carolina; 4Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; 5Department of Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota; 6Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts; 7Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania; and 8Respiratory Diseases Branch, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia The guideline is intended for use by healthcare providers who care for adult and pediatric patients with group A streptococcal pharyngitis. The guideline updates the 2002 Infectious Diseases Society of America guideline and discusses diagnosis and management, and recommendations are provided regarding antibiotic choices and dosing. Penicillin or amoxicillin remain the treatments of choice, and recommendations are made for the penicillin-allergic patient, which now include clindamycin. EXECUTIVE SUMMARY Group A streptococcal (GAS) pharyngitis is a significant cause of community-associated infections. This document constitutes a revision of the 2002 guideline of the Infectious Diseases Society of America (IDSA) on the treatment of GAS pharyngitis [1]. The primary objective of this guideline is to provide Received 3 July 2012; accepted 10 July 2012; electronically pubilshed 9 September 2012. Correspondence: Stanford T. Shulman, MD, Department of Pediatrics, Division of Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60611 (). Clinical Infectious Diseases 2012;55(10):1279–82 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: . DOI: 10.1093/cid/cis847 recommendations on the management of this very common clinical condition among adult and pediatric patients. The guideline addresses issues related to the diagnosis of streptococcal pharyngitis and its treatment in patients who are or are not allergic to penicillin. The guideline does not discuss active surveillance testing or other prevention strategies. Each section of the guideline begins with a specific clinical question and is followed by numbered recommendations and a summary of the most-relevant evidence in support of the recommendations. Areas of controversy in which data are limited or conflicting and in which additional research is needed are indicated throughout the document and are highlighted in the Future Research section. Summarized below are the recommendations made in the updated guidelines for the diagnosis and management GAS pharyngitis. The Panel followed a process used in the development of other IDSA guidelines, IDSA Guideline for GAS Pharyngitis • CID 2012:55 (15 November) • 1279 Table 1. Strength of Recommendations and Quality of the Evidence Strength of Recommendation and Quality of Evidence Clarity of Balance Between Desirable and Undesirable Effects Strong recommendation, high-quality evidence Methodological Quality of Supporting Evidence (Examples) Implications Desirable effects clearly outweigh undesirable effects, or vice versa Consistent evidence from wellperformed RCTs or exceptionally strong evidence from unbiased observational studies Recommendation can apply to most patients in most circumstances. Further research is unlikely to change our confidence in the estimate of effect. Strong recommendation, moderate quality evidence Desirable effects clearly outweigh undesirable effects, or vice versa Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies Recommendation can apply to most patients in most circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Strong recommendation, low-quality evidence Desirable effects clearly outweigh undesirable effects, or vice versa Evidence for at least 1 critical outcome from observational studies, RCTs with serious flaws or indirect evidence Recommendation may change when higher-quality evidence becomes available. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Strong recommendation, very-low-quality evidence (very rarely applicable) Desirable effects clearly outweigh undesirable effects, or vice versa Evidence for at least 1 critical outcome from unsystematic clinical observations or very indirect evidence Weak recommendation, high-quality evidence Desirable effects closely balanced with undesirable effects Consistent evidence from wellperformed RCTs or exceptionally strong evidence from unbiased observational studies Recommendation may change when higher-quality evidence becomes available. Any estimate of effect for at least 1 critical outcome is very uncertain. The best action may differ depending on circumstances or patients or societal values. Further research is unlikely to change our confidence in the estimate of effect. Weak recommendation, moderate-quality evidence Desirable effects closely balanced with undesirable effects Evidence from RCTs with important limitations (inconsistent results, methodological flaws, indirect, or imprecise) or exceptionally strong evidence from unbiased observational studies Alternative approaches likely to be better for some patients under some circumstances. Further research (if performed) is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Weak recommendation, low-quality evidence Uncertainty in the estimates of desirable effects, harms, and burden; desirable effects, harms, and burden may be closely balanced Evidence for at least 1 critical outcome from observational studies, from RCTs with serious flaws or indirect evidence Other alternatives may be equally reasonable. Further research is very likely to have an important impact on our confidence in the estimate of effe (...truncated)