Streptococcal Pharyngitis Is a Seasonal Concern

Pharyngitis, an inflammation of the back of the throat, can be bacterial or viral.

Streptococcal pharyngitis, commonly referred to as strep throat, is caused by Streptococcus pyogenes, group A β-hemolytic Streptococci (GAS).^1,2 GAS is responsible for fewer pharyngitis cases than viruses are (adults: 5%-15%, children: 20%-30%).^1-3 Strep throat spreads through direct contact with respiratory fluids and has an incubation period of 2 to 5 days.^2,3 Its prevalence increases during the winter and early spring, accounting for 1% to 2% of all ambulatory care visits in the United States.^2,4

Recognizing Signs/Symptoms

Differentiating between a bacterial and viral etiology is difficult, especially in pediatric patients, which often results in antibiotic overprescribing. Of note, patients who present with clear viral signs and symptoms (Table 1^1-6) do not require testing and should not receive antibiotics.^2,5,6 Conversely, symptoms of GAS pharyngitis are nonspecific.

Treatment: Antibiotics and Supportive Care

The Infectious Disease Society of America’s guidelines highly recommend antibiotic treatment in children who tested positive for strep throat. Treatment prevents nonsuppurative (eg, acute rheumatic fever [ARF], acute glomerulonephritis) and suppurative (eg, cervical lymphadenitis, mastoiditis, and peritonsillar abscess) complications.^2,4 Adult patients often do not need antibiotics because the relief they provide is minimal. Symptoms are self-limiting and usually last less than a week.⁴ Table 2^2-4,6-8 summarizes antibiotic therapy options. Guidelines consider amoxicillin/penicillin as first-line therapy, followed by cephalosporins and macrolides/azalides in the presence of allergy to first-line agents. Avoid fluoroquinolones, sulfonamides, and tetracyclines because of high resistance rates, ineffectiveness, and/or unnecessary broad-spectrum coverage.² Study results show that children experience more adverse events, notably gastrointestinal upset, when prescribed azalides/macrolides compared with β-lactam antibiotics. Rashes are more common with β-lactams.⁹

Guidelines do not recommend antibiotic use in asymptomatic individuals positive for GAS pharyngitis, as they are likely chronic carriers at no/minimal risk of complications and not contagious.^1-6 Similarly, recent exposure does not warrant testing if asymptomatic.^2,3,6 The exceptions are patients with family or personal histories of ARF and post-streptococcal glomerulonephritis. Asymptomatic and symptomatic GAS infections can prompt ARF recurrence. Experts also recommend secondary prophylaxis in patients with a history of ARF.^3,10

Key Counseling Points

Here are tips to share with patients:

• Avoid acidic or spicy foods, cleaning product fumes, and smoking.⁸
• Cover face when coughing or sneezing to prevent spread and use other hand hygiene.²
• Drink cold and hot fluids; eat cold, easy-to-swallow foods, such as popsicles; and get rest.^7,8
• Keep in mind that symptom improvement may take 1 to 3 days after starting treatment.²
• Stay home until feeling better, and wait at least 12 hours after starting antibiotics before return- ing to school or work.³
• Use a cool-mist humidified or vaporizer^7,8 (see Online Table 3 for more supportive care options).

Patients with clear viral symptoms do not require testing or antibiotics.² Children younger than 3 years of age do not require testing unless symptomatic with a known exposure.^2,6

Conclusion

Patients with pharyngitis often seek medical guidance. Assessing and counseling them on common adverse effects, hygiene, and supportive care prevent complications and transmission of infections. Pharmacists can help ensure the selection of appropriate antibiotic therapy.

Justyna Sudyka is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

REFERENCES

1. Ebell MH. Diagnosis of streptococcal pharyngitis. Am Fam Physician. 2014;89(12):976-977.2.
2. 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. 2014;58(10):1496.
3. [Dosage error in article text]. Clin Infect Dis. 2012;55(10):1279-1282. doi:10.1093/cid/cis8473.
4. Committee on Infectious Diseases, American Academy of Pediatrics, Kimberlin DW, Brady MT, Jackson MA, Long SS. Group A Streptococcal Infections. In: Red Book. 31st ed. American Academy of Pediatrics; 2018:748-762. Accessed March 3, 2021.https://redbook.solutions.aap.org/chapter.aspx?sectionid=189640187&bookid=22054.
5. Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164(6):425-434. doi:10.7326/M15-18405.
6. Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr. 2012;160(3):487-493.e3. doi:10.1016/j.jpeds.2011.09.0116.
7. Randel A; Infectious Disease Society of America. IDSA updates guideline for managing group A streptococcal pharyngitis.Am Fam Physician. 2013;88(5):338-340.7. Nationwide Children’s. Strep throat (bacterial). Updated October 2017. Accessed March 4, 2021.https://www.nationwidechildrens.org/conditions/strep-throat
8. Mayo Clinic. Strep throat: diagnosis and treatment. Accessed March 4, 2021. https://www.mayoclinic.org/diseases-conditions/strep-throat/diagnosis-treatment/drc-20350344
9. van Driel ML, De Sutter AI, Habraken H, Thorning S, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2016;9(9):CD004406. doi:10.1002/14651858.CD004406.pub410.
10. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009;119(11):1541-1551. doi:10.1161/CIRCULATIONAHA.109.191959