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Group A streptococcal pharyngitis

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 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 Physicians (ACP/CDC 2016), the Danish Health Authority (DHA 2016), the European Society for Microbiology and Infectious Diseases (ESCMID 2012), and the Infectious Diseases Society of America (IDSA 2012).


1.Screening and diagnosis

Indications for testing, symptomatic patients: 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).
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  • Indications for testing (asymptomatic contacts)

2.Classification and risk stratification

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

3.Diagnostic investigations

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

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  • Throat culture

  • Anti-streptococcal antibodies

  • Inflammatory markers

4.Medical management

Antibiotic therapy: as per AAFP 2023 guidelines, initiate antibiotics with penicillin as the first-line choice in patients with group A β-hemolytic streptococcal pharyngitis.

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  • Analgesics

  • Corticosteroids

  • Zinc gluconate

5.Nonpharmacologic interventions

Alternative medicine: insufficient evidence to support the use of herbal treatments and acupuncture as treatments for sore throat.

6.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.

7.Specific circumstances

Chronic GAS carriers
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
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.

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  • Asymptomatic household contacts

8.Follow-up and surveillance

Post-treatment throat culture: do not obtain routine follow-up post-treatment throat cultures or rapid antigen detection tests; consider these only in special circumstances.