Table of Contents

 

Emergency clinicians must recognize group A Streptococcus (GAS) pharyngitis and offer appropriate diagnosis and treatment to promote good antibiotic stewardship. In this issue, you will learn to:

Identify pediatric patients at risk for GAS pharyngitis and associated complications

Recognize the clinical signs and symptoms of GAS pharyngitis and differentiate them from viral and bacterial infections

Order rapid antigen detection testing or throat culture appropriately

Prescribe appropriate antibiotics for patients who need them, including alternatives for patients with beta-lactam allergies

Identify patients who may be discharged home, and those who need to be admitted for further management or observation

Recognize and manage various complications of GAS pharyngitis, such as peritonsillar abscess and acute rheumatic fever

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Modified/McIsaac Centor Criteria Clinical Scoring System
   2. Rapid Antigen Detection Testing/Throat Culture
   3. Antistreptococcal Antibody Titers
10. Treatment
    1. Treatment With Antibiotics
    2. Adjunctive Therapies
11. Special Circumstances
    1. Complications
       1. Suppurative Complications
          • Peritonsillar Abscess
          • Retropharyngeal Abscess
          • Cervical Lymphadenitis
          • Bacteremia
          • Necrotizing Faciitis
          • Streptococcal Toxic Shock Syndrome
       2. Nonsuppurative Complications
          • Acute Rheumatic Fever and Rheumatic Heart Disease
          • Poststreptococcal Glomerulonephritis
    2. GAS Carriers
12. Controversies and Cutting Edge
    1. Tonsillectomy
    2. Molecular-based Testing
    3. Vaccines
13. Disposition
14. Summary
15. Risk Management Pitfalls in the Management of Patients With Group A Streptococcal Pharyngitis
16. Time- and Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway for Management of Possible GAS Pharyngitis or Suppurative Complications in the Emergency Department
19. Tables and Figures
    1. Table 1. Modified-McIsaac Centor Criteria
    2. Table 2. Antibiotic Therapy Options for RADT- or Throat Culture-Positive GAS Pharyngitis
    3. Table 3. Adjunctive Therapy for GAS Pharyngitis
    4. Table 4. Jones Criteria for Acute Rheumatic Fever
    5. Table 5. Circumstances Requiring Treatment of GAS Carriers
    6. Table 6. Antibiotic Regimens for the Eradication of GAS Carriage
    7. Figure 1. Palatal Petechiae
    8. Figure 2. “Sandpapery” Scarlatiniform Rash
    9. Figure 3. Peritonsillar Abscess
20. References

Abstract

Although group A Streptococcus (GAS) pharyngitis is the most common cause of bacterial pharyngitis in children and adolescents, many viral and bacterial infections mimic the symptoms of GAS pharyngitis. Emergency clinicians must recognize the symptomatology of GAS pharyngitis and use appropriate means of diagnosis and treatment to promote good antibiotic stewardship. This issue reviews the signs and symptoms of GAS pharyngitis, as well as associated complications, and provides recommendations for appropriate treatment that focuses on reducing the severity and duration of symptoms, reducing the incidence of nonsuppurative complications, and reducing transmission.

Case Presentation

A previously healthy 5-year-old boy comes to the ED with fever and sore throat for the past 2 days. His mother reports that he had fevers as high as 39^oC (102.2^oF), decreased oral intake despite acetaminophen every 4 hours, malaise, headache, and abdominal pain with 1 episode of nonbilious, nonbloody emesis 2 hours prior to coming to the ED. The boy’s 9-year-old brother was started on treatment for streptococcal pharyngitis 2 days earlier. On examination, you notice the patient has bilateral enlarged tonsils with exudates and bilateral tender anterior cervical lymphadenopathy, with an otherwise negative physical examination. Due to his symptoms and physical examination findings, you perform a rapid antigen test for GAS pharyngitis, which is positive. When you discuss treatment options with his mother, she remembers that when he was treated with amoxicillin for an ear infection 2 years prior, he had an anaphylactic reaction to the medication. You begin to consider what would be the best treatment option for this patient...

A previously healthy 7-year-old girl comes to the ED with a 3-day history of a sore throat and rash. Her father says she has felt warm to the touch, but he has not taken her temperature. She also has had multiple episodes of nonbilious, nonbloody emesis and nonbloody diarrhea over the past 2 days, as well as decreased appetite. Her father has been most concerned about the worsening rash on her hands and feet. The review of systems is otherwise unremarkable. She has not received any medication at home for her tactile fevers or throat pain. The father said her school sent a note home saying multiple children in the school have had the same symptoms, and he was encouraged to keep her home until she is completely better. On examination, you note that she has multiple vesicles on her buccal mucosa and tonsillar fauces, with a bilateral maculopapular rash on her hands and feet. Her examination is otherwise unremarkable. The girls's father asks whether his daughter needs antibiotics to shorten the duration of her illness. What do you tell her father is the best treatment for her current illness?

A previously healthy 15-year-old girl comes to the ED with fever and sore throat. With a muffled voice, she tells you she’s had a worsening sore throat for 8 days and fever to 38.6^oC (101.5^oF) for the past 5 days. She has been spitting her saliva for the past 3 days, as it has been hard for her to swallow, and she has had difficulty opening her mouth over the past 2 days. She says she had “strep throat” 2 years ago, but it was nothing like this. She has been taking ibuprofen with minimal relief of her current symptoms. On her review of symptoms, she says her left ear has been hurting for the past 5 days as well. In the ED, she is noted to have a fever of 38^oC (100.4^oC) with a heart rate of 130 beats/min, respiratory rate of 12 breaths/min, and a blood pressure of 100/65 mm Hg. On examination, you notice she has dry mucous membranes, capillary refill of 3 seconds, trismus, and, with the use of a tongue depressor, you see a very large left tonsil with exudates and fullness of the soft palate, as well as uvular deviation to the right side. Her physical examination is otherwise unremarkable. What should be the next steps in treating this patient?

Introduction

Children frequently present to emergency departments (EDs) and urgent care centers with the chief complaint of sore throat. One study estimates that only 20% to 30% of these children have an acute infection with streptococcal pharyngitis.¹ Group A Streptococcus (GAS) pharyngitis is the most common cause of bacterial pharyngitis in children and adolescents, and it may lead to suppurative and nonsuppurative complications. Suppurative complications include peritonsillar abscess (PTA) and, less commonly, streptococcal toxic shock syndrome (STSS) and other invasive infections. Nonsuppurative complications include acute rheumatic fever (ARF) and acute poststreptococcal glomerulonephritis (PSGN). Treatment of streptococcal pharyngitis is primarily aimed at preventing ARF,² which is rarely seen in developed nations,^3,4 but should be considered in areas with a large immigrant population.

Common pitfalls in the management of streptococcal pharyngitis include inappropriate testing of obvious viral etiologies and assuming that all positive screens/cultures indicate an acute infection rather than a carrier state of GAS. Inappropriate use of antimicrobials for acute pharyngitis has been a major contributor to the development of antibiotic-resistant bacteria.^5-7 It is imperative that emergency clinicians recognize the symptomatology and preserve the integrity of narrow-spectrum antibiotics for this common infection. This issue of Pediatric Emergency Medicine Practice focuses on recognizing the clinical signs and symptoms of GAS pharyngitis to facilitate appropriate treatment and to promote good antibiotic stewardship.

Critical Appraisal of the Literature

An online literature search was performed using the PubMed and Ovid MEDLINE^® databases, with the search terms pediatric streptococcal pharyngitis treatment, pediatric streptococcal pharyngitis diagnosis, streptococcal pharyngitis testing, pharyngitis treatment, pediatric sore throat, and sore throat. A total of 167 articles were found, and 153 articles were reviewed. Overall, there is a moderate amount of high-quality evidence evaluating the diagnosis and treatment of GAS pharyngitis. There were 13 meta-analyses found in journals and the Cochrane Database of Systematic Reviews that examined different aspects of GAS pharyngitis. Of the 153 articles included in this review, there were 36 randomized controlled trials examining current and possible future diagnostic and therapeutic options for GAS pharyngitis. The most recent Infectious Diseases Society of America (IDSA) guideline entitled, “Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America” was also reviewed.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

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2. 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. (Scientific statement)
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35. * 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):1279-1282. (Clinical practice guideline)
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47. Dingle TC, Abbott AN, Fang FC. Reflexive culture in adolescents and adults with group A streptococcal pharyngitis. Clin Infect Dis. 2014;59(5):643-650. (Retrospective study; 726 patients)
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49. Baron EJ, Miller JM, Weinstein MP, et al. A guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2013 recommendations by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis. 2013;57(4):485-488. (IDSA recommendations)
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71. Shulman ST, Gerber MA, Tanz RR, et al. Streptococcal pharyngitis: the case for penicillin therapy. Pediatr Infect Dis J. 1994;13(1):1-7. (Review)
72. Feder HM Jr, Gerber MA, Randolph MF, et al. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics. 1999;103(1):47-51. (Investigator-blinded randomized controlled trial; 152 patients)
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78. * van Driel ML, De Sutter AI, Keber N, et al. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2013(4):CD004406. (Cochrane meta-analysis; 17 trials, 5352 participants)
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83. Nemeth MA, McCarty J, Gooch WM 3rd, et al. Comparison of cefdinir and penicillin for the treatment of streptococcal pharyngitis. Cefdinir Pharyngitis Study Group. Clin Ther. 1999;21(11):1873-1881. (Randomized double-blinded controlled trial; 644 patients)
84. Pichichero ME, Gooch WM, Rodriguez W, et al. Effective short-course treatment of acute group A beta-hemolytic streptococcal tonsillopharyngitis. Ten days of penicillin V vs 5 days or 10 days of cefpodoxime therapy in children. Arch Pediatr Adolesc Med. 1994;148(10):1053-1060. (Investigator-blinded randomized controlled trial; 377 patients)
85. Portier H, Chavanet P, Waldner-Combernoux A, et al. Five versus ten days treatment of streptococcal pharyngotonsillitis: a randomized controlled trial comparing cefpodoxime proxetil and phenoxymethyl penicillin. Scand J Infect Dis. 1994;26(1):59-66. (Randomized controlled trial; 220 patients)
86. Pichichero ME. A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients. Pediatrics. 2005;115(4):1048-1057. (Review)
87. Hooton TM. A comparison of azithromycin and penicillin V for the treatment of streptococcal pharyngitis. Am J Med. 1991;91(3A):23S-26S. (Randomized controlled trial; 242 patients)
88. Tanz RR, Shulman ST, Shortridge VD, et al. Community-based surveillance in the United States of macrolide-resistant pediatric pharyngeal group A streptococci during 3 respiratory disease seasons. Clin Infect Dis. 2004;39(12):1794-1801. (Prospective trial; 2888 cultures)
89. Seppälä H, Nissinen A, Jarvinen H, et al. Resistance to erythromycin in group A streptococci. N Engl J Med. 1992;326(5):292-297. (Retrospective study; 4436 isolates)
90. Bergman M, Huikko S, Pihlajamaki M, et al. Effect of macrolide consumption on erythromycin resistance in Streptococcus pyogenes in Finland in 1997-2001. Clin Infect Dis. 2004;38(9):1251-1256. (Retrospective study; 50,875 isolates)
91. Gerber MA. Antibiotic resistance in group A streptococci. Pediatr Clin North Am. 1995;42(3):539-551. (Review)
92. Coonan KM, Kaplan EL. In vitro susceptibility of recent North American group A streptococcal isolates to eleven oral antibiotics. Pediatr Infect Dis J. 1994;13(7):630-635. (Prospective trial; 325 isolates)
93. Wickman PA, Black JA, Moland ES, et al. In vitro activities of DX-619 and comparison quinolones against gram-positive cocci. Antimicrob Agents Chemother. 2006;50(6):2255-2257. (Prospective trial; 228 isolates)
94. Wilcox MH. The tide of antimicrobial resistance and selection. Int J Antimicrob Agents. 2009;34 Suppl 3:S6-S10. (Review)
95. Colodner R, Rock W, Chazan B, et al. Risk factors for the development of extended-spectrum beta-lactamase-producing bacteria in nonhospitalized patients. Eur J Clin Microbiol Infect Dis. 2004;23(3):163-167. (Prospective trial; 311 cultures)
96. Ng GJ, Tan S, Vu AN, et al. Antibiotics for preventing recurrent sore throat. Cochrane Database Syst Rev. 2015(7):CD008911. (Cochrane meta-analysis; no trials identified)
97. Schachtel BP, Thoden WR. A placebo-controlled model for assaying systemic analgesics in children. Clin Pharmacol Ther. 1993;53(5):593-601. (Double-blinded placebo-controlled trial; 78 patients)
98. Gehanno P, Dreiser RL, Ionescu E, et al. Lowest effective single dose of diclofenac for antipyretic and analgesic effects in acute febrile sore throat. Clin Drug Investig. 2003;23(4):263-271. (Randomized double-blinded controlled trial; 343 patients)
99. Bertin L, Pons G, d’Athis P, et al. Randomized, double-blind, multicenter, controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children. J Pediatr. 1991;119(5):811-814. (Randomized controlled trial; 231 patients)
100. Thomas M, Del Mar C, Glasziou P. How effective are treatments other than antibiotics for acute sore throat? Br J Gen Pract. 2000;50(459):817-820. (Meta-analysis; 17 trials)
101. Beutler AI, Chesnut GT, Mattingly JC, et al. FPIN’s clinical inquiries. Aspirin use in children for fever or viral syndromes. Am Fam Physician. 2009;80(12):1472. (Review)
102. Prior MJ, Nelson EB, Temple AR. Pediatric ibuprofen use increases while incidence of Reye’s syndrome continues to decline. Clin Pediatr (Phila). 2000;39(4):245-247. (Review)
103. Belay ED, Bresee JS, Holman RC, et al. Reye’s syndrome in the United States from 1981 through 1997. N Engl J Med. 1999;340(18):1377-1382. (Retrospective study; 1207 patients)
104. Sullivan KM, Belay ED, Durbin RE, et al. Epidemiology of Reye’s syndrome, United States, 1991-1994: comparison of CDC surveillance and hospital admission data. Neuroepidemiology. 2000;19(6):338-344. (Retrospective study; 284 patients)
105. McNally D, Shephard A, Field E. Randomised, double-blind, placebo-controlled study of a single dose of an amylmetacresol/2,4-dichlorobenzyl alcohol plus lidocaine lozenge or a hexylresorcinol lozenge for the treatment of acute sore throat due to upper respiratory tract infection. J Pharm Pharm Sci. 2012;15(2):281-294. (Randomized double-blinded controlled trial; 190 patients)
106. McNally D, Simpson M, Morris C, et al. Rapid relief of acute sore throat with AMC/DCBA throat lozenges: randomised controlled trial. Int J Clin Pract. 2010;64(2):194-207. (Randomized double-blinded controlled trial; 310 patients)
107. Hayward G, Thompson MJ, Perera R, et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012;10:CD008268. (Cochrane meta-analysis; 8 trials, 743 patients)
108. Chiappini E, Bortone B, Di Mauro G, et al. Choosing wisely: the top-5 recommendations from the Italian panel of the National Guidelines for the Management of Acute Pharyngitis in Children. Clin Ther. 2017;39(3):646-649. (Clinical practice guidelines)
109. Little P, Stuart B, Hobbs FD, et al. Predictors of suppurative complications for acute sore throat in primary care: prospective clinical cohort study. BMJ. 2013;347:f6867. (Prospective clinical cohort study; 14,610 patients)
110. Knorr TL, Sinha V. Abscess, retropharyngeal. StatPearls. Treasure Island (FL): StatPearls Publishing; 2017. (Review)
111. Zimbelman J, Palmer A, Todd J. Improved outcome of clindamycin compared with beta-lactam antibiotic treatment for invasive Streptococcus pyogenes infection. Pediatr Infect Dis J. 1999;18(12):1096-1100. (Retrospective; 56 patients)
112. Stevens DL, Tanner MH, Winship J, et al. Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med. 1989;321(1):1-7. (Prospective; 20 patients)
113. Chiang MC, Jaing TH, Wu CT, et al. Streptococcal toxic shock syndrome in children without skin and soft tissue infection: report of four cases. Acta Paediatr. 2005;94(6):763-765. (Case series; 4 patients)
114. Richter SS, Heilmann KP, Beekmann SE, et al. Macrolide-resistant Streptococcus pyogenes in the United States, 2002-2003. Clin Infect Dis. 2005;41(5):599-608. (In vitro study; 1885 isolates)
115. Carapetis JR, Jacoby P, Carville K, et al. Effectiveness of clindamycin and intravenous immunoglobulin, and risk of disease in contacts, in invasive group a streptococcal infections. Clin Infect Dis. 2014;59(3):358-365. (Prospective; 84 patients)
116. Kaul R, McGeer A, Norrby-Teglund A, et al. Intravenous immunoglobulin therapy for streptococcal toxic shock syndrome--a comparative observational study. The Canadian Streptococcal Study Group. Clin Infect Dis. 1999;28(4):800-807. (Case control study; 53 patients)
117. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues. N Engl J Med. 1996;334(4):240-245. (Review)
118. Stevens DL, Bryant AE, Hackett SP, et al. Group A streptococcal bacteremia: the role of tumor necrosis factor in shock and organ failure. J Infect Dis. 1996;173(3):619-626. (Review)
119. Ilgenfritz S, Dowlatshahi C, Salkind A. Acute rheumatic fever: case report and review for emergency physicians. J Emerg Med. 2013;45(4):e103-e106. (Case report)
120. * Gewitz MH, Baltimore RS, Tani LY, et al. Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association. Circulation. 2015;131(20):1806-1818. (Scientific statement)
121. Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992;268(15):2069-2073. (Guidelines)
122. Cilliers A, Adler AJ, Saloojee H. Anti-inflammatory treatment for carditis in acute rheumatic fever. Cochrane Database of Syst Rev. 2015(5):CD003176. (Cochrane meta-analysis; 8 studies)
123. Eison TM, Ault BH, Jones DP, et al. Post-streptococcal acute glomerulonephritis in children: clinical features and pathogenesis. Pediatr Nephrol. 2011;26(2):165-180. (Review)
124. Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005;366(9480):155-168. (Review)
125. Gerber MA, Tanz RR, Kabat W, et al. Potential mechanisms for failure to eradicate group A streptococci from the pharynx. Pediatrics. 1999;104(4 Pt 1):911-917. (Prospective randomized trial; 462 patients)
126. Tanz RR, Shulman ST, Barthel MJ, et al. Penicillin plus rifampin eradicates pharyngeal carriage of group A streptococci. J Pediatr. 1985;106(6):876-880. (Randomized controlled trial; 37 patients)
127. Tanz RR, Poncher JR, Corydon KE, et al. Clindamycin treatment of chronic pharyngeal carriage of group A streptococci. J Pediatr. 1991;119(1 Pt 1):123-128. (Randomized controlled trial; 48 patients)
128. Kaplan EL, Gooch IW, Notario GF, et al. Macrolide therapy of group A streptococcal pharyngitis: 10 days of macrolide therapy (clarithromycin) is more effective in streptococcal eradication than 5 days (azithromycin). Clin Infect Dis. 2001;32(12):1798-1802. (Investigator-blinded parallel-group study; 392 patients)
129. Klein JO. Management of streptococcal pharyngitis. Pediatr Infect Dis J. 1994;13(6):572-575. (Review)
130. Kaplan EL, Gastanaduy AS, Huwe BB. The role of the carrier in treatment failures after antibiotic for group A streptococci in the upper respiratory tract. J Lab Clin Med. 1981;98(3):326-335. (Prospective study; 280 patients)
131. Martin JM, Green M, Barbadora KA, et al. Group A streptococci among school-aged children: clinical characteristics and the carrier state. Pediatrics. 2004;114(5):1212-1219. (Prospectivie longitudinal study; 125 patients)
132. Shulman ST. Streptococcal pharyngitis: diagnostic considerations. Pediatr Infect Dis J. 1994;13(6):567-571. (Review)
133. Kikuta H, Shibata M, Nakata S, et al. Efficacy of antibiotic prophylaxis for intrafamilial transmission of group A beta-hemolytic streptococci. Pediatr Infect Dis J. 2007;26(2):139-141. (Randomized controlled trial; 1440 patients)
134. Chaudhary S, Bilinsky SA, Hennessy JL, et al. Penicillin V and rifampin for the treatment of group A streptococcal pharyngitis: a randomized trial of 10 days penicillin vs 10 days penicillin with rifampin during the final 4 days of therapy. J Pediatr. 1985;106(3):481-486. (Prospective randomized controlled trial; 79 patients)
135. Kaplan EL, Johnson DR. Eradication of group A streptococci from the upper respiratory tract by amoxicillin with clavulanate after oral penicillin V treatment failure. J Pediatr. 1988;113(2):400-403. (Prospective study; 295 patients)
136. Paradise JL, Bluestone CD, Bachman RZ, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984;310(11):674-683. (Prospective randomized controlled trial; 187 patients)
137. Paradise JL, Bluestone CD, Colborn DK, et al. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics. 2002;110(1 Pt 1):7-15. (Parallel Randomized controlled trials; 328 patients)
138. Discolo CM, Darrow DH, Koltai PJ. Infectious indications for tonsillectomy. Pediatr Clin North Am. 2003;50(2):445-458. (Review)
139. Baugh RF, Archer SM, Mitchell RB, et al. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(1 Suppl):S1-S30. (Clinical practice guideline)
140. Corneli HM. Rapid detection and diagnosis of group A streptococcal pharyngitis. Curr Infect Dis Rep. 2004;6(3):181-186. (Review)
141. Leung AK, Newman R, Kumar A, et al. Rapid antigen detection testing in diagnosing group A beta-hemolytic streptococcal pharyngitis. Expert Rev Mol Diagn. 2006;6(5):761-766. (Review)
142. Chapin KC, Blake P, Wilson CD. Performance characteristics and utilization of rapid antigen test, DNA probe, and culture for detection of group a streptococci in an acute care clinic. J Clin Microbiol. 2002;40(11):4207-4210. (Randomized controlled trial; 520 patients)
143. Anderson NW, Buchan BW, Mayne D, et al. Multicenter clinical evaluation of the illumigene group A streptococcus DNA amplification assay for detection of group A streptococcus from pharyngeal swabs. J Clin Microbiol. 2013;51(5):1474-1477. (Prospective trial; 796 specimens)
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Centor Score

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• Introduction
• Points & Pearls
• Why and When to Use, and Next Steps
• Calculator Review Authors
• Critical Actions
• Evidence Appraisal
• Calculator Creator
• References
• Related Calculator

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• The Centor Score correlates directly with the risk of a throat culture that is positive for group A Streptococcus (GAS).
• The most recently updated guideline from the Infectious Diseases Society of America for diagnosis and management of GAS pharyngitis no longer recommends empiric treatment. The new recommendation is to test patients who are at higher risk for GAS pharyngitis, but give antibiotics only when a patient’s rapid antigen detection test or throat culture is positive for GAS (Shulman et al 2012).
• The modified criteria designated by McIsaac et al (2004) include an age component, along with tonsillar swelling. GAS is incredibly rare in patients aged < 3 years, and is also less common in older adults, so the age component can help clinicians risk stratify patients.
• Most cases of pharyngitis are viral in origin. Given the rare incidence of acute rheumatic fever, along with the questionable benefits of early antibiotics to prevent sequelae like peritonsillar abscess, antibiotics are now prescribed much less often. Steroids (such as dexamethasone) and NSAIDs (nonsteroidal anti-inflammatory drugs) often provide similar pain relief and resolution of symptoms to antibiotics.

Why and When to Use, and Next Steps 

Calculator Review Authors 

Graham Walker, MD  

Department of Emergency Medicine

Kaiser Permanente San Francisco 

San Francisco, CA

Rachel Kwon, MD

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Critical Actions

It is still important to carefully consider patients with symptom duration longer than 3 days, even though the Centor Score does not apply. While symptoms are not compatible with a diagnosis of acute pharyngitis, these patients require evaluation for suppurative complications (eg, peritonsillar abscess or Lemierre syndrome), or viral infections in adult patients (eg, infectious mononucleosis or acute HIV) (Centor 2017).

Evidence Appraisal

The goal of the original study by Centor et al was to develop criteria to diagnose GAS infection in adult patients presenting to the emergency department with a sore throat (Centor et al 1981). The original model designated 4 criteria: tonsillar exudates; swollen, tender anterior cervical nodes; absence of cough; and history of fever. Patients exhibiting all 4 variables had a 56% probability of having a group A beta strep-positive culture; the probability was 32% in patients with 3 variables, 15% in patients with 2 variables, 6.5% in patients with 1 variable, and 2.5% in patients with none of the variables.

The Centor Score was later modified to include age (McIsaac et al 1998) and was validated (McIsaac et al 2004) for use in both children and adults presenting with a sore throat. McIsaac et al (1998) determined that using the Centor Score would reduce the number of unnecessary initial antibiotic prescriptions by 48%, without increasing throat culture use.

The Centor Score and its modifications were derived in relatively small samples (n = 286 and n = 521, respectively). In order to more precisely classify the risk of GAS infection, Fine et al (2012) performed a national-scale validation of the score on a geographically diverse population of > 140,000 patients presenting in a clinical setting. The study was carried out over the course of more than a year, mitigating any impact of seasonality of GAS incidence on the results. This analysis provided more precise interpretations of risk for each category of the Centor Score and still fell within the 95% confidence interval of the original study by Centor et al (1981), which had a much smaller sample size.

In their comparison of the Centor Score with other identification and treatment strategies, McIsaac et al (2004) found that use of the score resulted in fewer overall tests (throat cultures and rapid antigen detection tests) per person, but more throat cultures (96.1% of adults) than other strategies. As a result, the Centor Score represented a compromise, requiring the least diagnostic testing, providing 100% sensitivity and greater than 90% specificity in both children and adults, and producing significant reductions in unnecessary use of antibiotics, compared with other strategies.

Harris et al (2016) encouraged the use of the Centor Score primarily to identify patients with a low probability of GAS pharyngitis who do not warrant further testing, citing the low positive predictive value of the criteria.

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Robert M. Centor, MD

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References

Original/Primary Reference

• Centor RM, Witherspoon JM, Dalton HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-246.
• McIsaac WJ, White D, Tannenbaum D, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75-83.

Validation

• Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847-852.
• McIsaac WJ, Kellner JD, Aufricht P, et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA. 2004;291(13):1587-1595.

Other References

• Shulman ST, Bisno AL, Clegg HW, et al. Executive summary: 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):1279-1282.
• Harris AM, Hicks LA, Qaseem A, et al. 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.
• Mitchell MS, Sorrentino A, Centor RM. Adolescent pharyngitis: a review of bacterial causes. Clin Pediatr (Phila). 2011;50(12):1091-1095.
• Centor R. Centor's corner: FeverPAIN versus Centor Score. Paging MDCalc [blog]. Available at: http://paging.mdcalc.com/2017/08/18/centors-corner-feverpain-versus-centorscore/. Accessed November 16, 2017.

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• Access the FeverPAIN Score for Strep Pharyngitis.

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