Wise Use of Antibiotics: Managing the Child with Pharyngitis

Column Author & Editor: Rana El Feghaly, MD, MSCI | Director, Clinical Services | Director, Outpatient Antibiotic Stewardship Program | Associate Professor of Pediatrics, UMKC School of Medicine

With pharyngitis being one of the most common diagnoses seen in ambulatory pediatrics, you’d think its management is straightforward. With the variability in clinical guidelines, difficulty differentiating viral from bacterial pharyngitis, and the never-ending concerns of complications of Streptococcus pyogenes (group A streptococcus [GAS]) infections, this diagnosis becomes much more complex than originally thought. Children’s Mercy Evidence-Based Practice recently reviewed the literature to help support you in managing children presenting with sore throat. 

Why is everyone worried about GAS infections?

As an infectious diseases physician, I tell my trainees I am allowed to choose one least favorite bacteria, and it is GAS! You may ask why, since GAS is such a common bacterium and seems to be relatively easy to treat. The answer is its capability to cause severe disease. From invasive disease to toxin-mediated reactions to non-suppurative late complications, GAS is a bacterium capable of substantial inflammation and damage. Even so, and despite the recent increase in invasive GAS infections,¹ the vast majority of these complications are not due to a delayed GAS pharyngitis diagnosis or treatment. In fact, direct complications of GAS pharyngitis are rare.²

• Peritonsillar abscess, one of the most common deep neck infections in adolescents, typically a complication of GAS pharyngitis, occurs in only 40-170 per 100,000 persons 5-59 years of age. These patients usually present with severe sore throat that may progress to drooling, muffled voice and, ultimately, if not treated, upper airway obstruction.²
• Retropharyngeal abscess, a deep neck infection typically seen in toddlers, has an incidence of two to four per 100,000 children, with the potential initial infection being pharyngitis, tonsilitis or adenitis. This infection, which presents with fever, sore throat, odynophagia and neck pain, is often polymicrobial.²
• Parapharyngeal abscess is even rarer, with an incidence of one per 100,000.²

Studies of invasive GAS infections such as toxic shock syndrome, sepsis, necrotizing fasciitis, mastoiditis, central nervous system infections, pneumonia, and musculoskeletal infections, rarely find pharyngitis as a source.³

As for non-suppurative late complications, acute rheumatic fever (ARF) is the main complication linked to a preceding pharyngitis, and its incidence in the U.S. is less than two cases per 100,000 school-aged children.^4,5

When should I be suspicious for GAS pharyngitis?

Streptococcal pharyngitis, the most common cause of bacterial pharyngitis, peaks in late fall and winter in temperate climates, with a peak in children 7-8 years of age. Children younger than 3 years of age are unlikely to get GAS pharyngitis and should generally be tested only if they are symptomatic and have strong exposure. GAS pharyngitis typically presents with the abrupt onset of sore throat commonly associated with fevers. It can be associated with headaches, neck swelling, vomiting or abdominal pain. Fever alone without a sore throat makes GAS pharyngitis less likely. The presence of viral symptoms such as cough, hoarseness, rhinorrhea, congestion, conjunctivitis, mouth ulcers or diarrhea should raise suspicions of viral pharyngitis, which is much more common than bacterial pharyngitis. Consistent clinical exam findings, although non-specific for streptococcal pharyngitis, include tonsillopharyngeal erythema, swelling or exudates, inflamed uvula, palatal petechiae, tender anterior cervical lymphadenopathy, and strawberry tongue. A scarlatiniform rash (typically described as sandpapery), if associated with pharyngitis, is generally specific for GAS, although it can also occur with other infections such as Arcanobacterium haemolyticum in adolescents.^6,7

Why should I NOT perform GAS testing on children with viral symptoms and pharyngitis?

Up to 25% of asymptomatic patients are GAS carriers.⁶ Picking up this bacterium on these patients exposes them to unnecessary antibiotics, their side effects, and risk of allergy label if they develop a viral rash while on antibiotics. As importantly, GAS often becomes an anchoring diagnosis, and critical alternate diagnoses may be missed. I have seen countless patients misdiagnosed as GAS pharyngitis who are ultimately diagnosed with Kawasaki diseases, urinary tract infections, or other serious conditions that were missed due to the positive streptococcal testing.

How should I treat GAS pharyngitis? 

Multiple international guidelines advise against treating GAS pharyngitis given that it clinically improves spontaneously even without antibiotics.^8,9 However, U.S. guidelines continue to recommend antibiotics to avoid suppurative complications and ARF.⁶ Thankfully, to date, no reported penicillin resistance among GAS has been reported. Therefore, penicillin and amoxicillin continue to be the drugs of choice.¹⁰ A once-daily amoxicillin dose has been proven to be as effective as multiple daily dosing.¹¹ Given the ease of administration and the improved adherence, we favor once-daily amoxicillin dosing for GAS pharyngitis. Finally, although multiple studies suggest that a five- to seven-day course may be sufficient in treating GAS pharyngitis,^12,13 since the evidence is not robust yet, we continue to support the U.S. guidelines that recommend 10 days.⁶

Where can I find more information on the topic?

You can access the updated Children’s Mercy Clinical Pathway on the following link:

Pharyngitis | Children's Mercy Kansas City (childrensmercy.org)

References:

1. Increase in pediatric invasive group A streptococcal infections. Centers for Disease Control and Prevention. Published 2023. Accessed February 1, 2024. https://emergency.cdc.gov/han/2022/han00484.asp
2. Tebruegge M, Zimmermann P, Curtis N. Infections related to the upper and middle airways. In: Long S, Prober CG, Fischer M, Kimberlin D, eds. Principles and Practice of Pediatric Infectious Diseases. 6th ed. Elsevier; 2023:212-220.e216.
3. Nelson GE, Pondo T, Toews KA, et al. Epidemiology of invasive group A streptococcal infections in the United States, 2005-2012. Clin Infect Dis. 2016;63(4):478-486.
4. Watkins DA, Johnson CO, Colquhoun SM, et al. Global, regional, and national burden of rheumatic heart disease, 1990-2015. N Engl J Med. 2017;377(8):713-722.
5. Acute rheumatic fever. Centers for Disease Control and Prevention. Published 2022. Accessed February 1, 2024. https://www.cdc.gov/groupastrep/diseases-hcp/acute-rheumatic-fever.html
6. 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. 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. 2012;55(10):e86-e102.
8. Pellegrino R, Timitilli E, Verga MC, et al. Acute pharyngitis in children and adults: descriptive comparison of current recommendations from national and international guidelines and future perspectives. Eur J Pediatr. 2023;182(12):5259-5273.
9. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev. 2021;12(12):CD000023.
10. Group A streptococcal (GAS) disease. Centers for Disease Control and Prevention. Published 2022. Accessed February 2, 2024. https://www.cdc.gov/groupastrep/surveillance.html
11. Nakao A, Hisata K, Fujimori M, et al. Amoxicillin effect on bacterial load in group A streptococcal pharyngitis: comparison of single and multiple daily dosage regimens. BMC Pediatr. 2019;19(1):205.
12. Salinas Salvador B, Moreno Sanchez A, Carmen Marcen G, et al. Retrospective study on the effectiveness and safety of the shortened 5- to 7-day antibiotic regimen for acute streptococcal pharyngotonsillitis compared to the classic 10-day regimen. An Pediatr (Engl Ed). 2022;97(6):398-404.
13. Falagas ME, Vouloumanou EK, Matthaiou DK, Kapaskelis AM, Karageorgopoulos DE. Effectiveness and safety of short-course vs long-course antibiotic therapy for group a beta hemolytic streptococcal tonsillopharyngitis: a meta-analysis of randomized trials. Mayo Clin Proc. 2008;83(8):880-889.