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Group A streptococcal pharyngitis

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Updated 2024 AAFP guidelines for the diagnosis and management of group A streptococcal pharyngitis.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of group A streptococcal pharyngitis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024,2023), the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2019), the American Academy of Pediatrics (AAP 2018), the British Medical Journal (BMJ 2017), the American College of ...
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Screening and diagnosis

Indications for testing, symptomatic patients: as per ACP/CDC 2016 guidelines, obtain rapid antigen detection test and/or culture for group A Streptococcus in patients with symptoms suggestive of GAS pharyngitis (such as persistent fever, anterior cervical lymphadenopathy, and tonsillar/pharyngeal exudate, or other appropriate combination of symptoms).
B
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  • Indications for testing (asymptomatic contacts)

  • Diagnosis

Classification and risk stratification

Risk assessment: as per AAFP 2023 guidelines, consider using a clinical scoring scale, such as the Centor score, in the initial evaluation of pharyngitis and tonsillitis symptoms.
B

Diagnostic investigations

Rapid antigen detection test: as per AAFP 2023 guidelines, consider obtaining rapid antigen detection testing in patients with a Centor score of ≥ 2.
B

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  • Throat culture

  • Anti-streptococcal antibodies

  • Inflammatory markers

Medical management

Antibiotic therapy
As per AAFP 2024 guidelines:
Initiate penicillin or amoxicillin as the first-line antibiotic for GAS pharyngitis.
A
Do not use azithromycin GAS pharyngitis unless the patient is allergic to β-lactams.
D

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  • Analgesics

  • Corticosteroids

  • Zinc gluconate

Nonpharmacologic interventions

Alternative medicine: as per ESCMID 2012 guidelines, insufficient evidence to support the use of herbal treatments and acupuncture as treatments for sore throat.
I

Surgical interventions

Indications for tonsillectomy: as per AAFP 2023 guidelines, offer watchful waiting over tonsillectomy in patients with recurrent tonsillitis with:
< 7 episodes in the past year
< 5 episodes per year in the past 2 years
< 3 episodes per year in the past 3 years.
A

Specific circumstances

Chronic group A streptococcal carriers
As per IDSA 2012 guidelines:
Recognize that recurrent episodes of pharyngitis in patients with laboratory evidence of group A streptococcal infection may represent either:
multiple episodes of bona fide recurrent streptococcal pharyngitis at close intervals, or
multiple episodes of viral pharyngitis in chronic pharyngeal group A streptococcus carriers
B
Do not attempt to identify nor administer antimicrobial therapy in patients with asymptomatic group A streptococcus carriage, as they are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or non-suppurative complications, such as acute rheumatic fever.
D

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  • Asymptomatic household contacts

Follow-up and surveillance

Post-treatment throat culture: as per IDSA 2012 guidelines, do not obtain routine follow-up post-treatment throat cultures or rapid antigen detection tests; consider these only in special circumstances.
D