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 recommendations on the management of this very Received 3 July 2012; accepted 10 July 2012; electronically published 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):e86–102 © 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/cis629 e86 • CID 2012:55 (15 November) • Shulman et al 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, which included a systematic weighting of the strength of recommendation (ie, “strong” or “weak”) and quality of evidence (ie, “high,” “moderate,” “low,” or “very low”), using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system [2–8] (Table 1). A detailed description of the methods, background, and evidence summaries that support each of the recommendations can be found in the full text of the guidelines. Specific treatment recommendations regarding streptococcal pharyngitis are included in Table 2. 7. Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended (strong, moderate). RECOMMENDATIONS FOR THE TREATMENT OF PATIENTS WITH GAS PHARYNGITIS III. What Are the Treatment Recommendations for Patients With a Diagnosis of GAS Pharyngitis? RECOMMENDATIONS FOR THE DIAGNOSIS OF GAS PHARYNGITIS I. How Should the Diagnosis of GAS Pharyngitis Be Established? Recommendations 1. Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present. In children and adolescents, negative RADT tests should be backed up by a throat culture (strong, high). Positive RADTs do not necessitate a back-up culture because they are highly specific (strong, high). 2. Routine use of back-up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances, because of the low incidence of GAS pharyngitis in adults and because the risk of subsequent acute rheumatic fever is generally exceptionally low in adults with acute pharyngitis (strong, moderate). Physicians who wish to ensure they are achieving maximal sensitivity in diagnosis may continue to use conventional throat culture or to back up negative RADTs with a culture. 3. Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis as they reflect past but not current events; strong, high). II. Who Should Undergo Testing for GAS Pharyngitis? Recommendations 4. Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers; strong, high). 5. Diagnostic studies for GAS pharyngitis are not indicated for children <3 years old because acute rheumatic fever is rare in children <3 years old and the incidence of streptococcal pharyngitis and the classic presentation of streptococcal pharyngitis are uncommon in this age group. Selected children <3 years old who have other risk factors, such as an older sibling with GAS infection, may be considered for testing (strong, moderate). 6. Follow-up posttreatment throat cultures or RADT are not recommended routinely but may be considered in special circumstances (strong, high). Recommendations 8. Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days). Based on their narrow spectrum of activity, infrequency (...truncated)