View source for Streptococcal pharyngitis

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{{Infobox medical condition (new)
| name = Streptococcal pharyngitis
| image = Pos strep.JPG
| caption = A culture positive case of streptococcal pharyngitis with typical tonsillar [[exudate]] in a 16-year-old
| alt = A set of large tonsils in the back of the throat covered in white exudate
| field = [[Infectious disease (medical specialty)|Infectious disease]]
| synonyms = Streptococcal sore throat, strep throat
| symptoms = Fever, sore throat, enlarged lymph nodes<ref name=CDC21015/>
| onset = 1–3 days after exposure<ref name=Tor2011/><ref name=Goroll2009/>
| duration = 7–10 days<ref name=Tor2011/><ref name=Goroll2009/>
| causes = ''[[Group A streptococcus]]''<ref name=CDC21015/>
| risks = Sharing drinks or eating utensils<ref name=risk>{{cite web |title=Strep throat - Symptoms and causes |url=https://www.mayoclinic.org/diseases-conditions/strep-throat/symptoms-causes/syc-20350338 |website=Mayo Clinic |access-date=24 January 2020 |language=en}}</ref>
| diagnosis = [[Throat culture]], [[strep test]]<ref name=CDC21015/>
| differential = [[Epiglottitis]], [[infectious mononucleosis]], [[Ludwig's angina]], [[peritonsillar abscess]], [[retropharyngeal abscess]], [[viral pharyngitis]]<ref name=Got2018/>
| prevention = Handwashing,<ref name=CDC21015/> covering coughs<ref name=risk/>
| treatment = [[Paracetamol]] (acetaminophen), [[NSAIDs]], [[antibiotics]]<ref name=CDC21015/><ref name=Web2014/>
| medication = 
| frequency = 5 to 40% of sore throats<ref name=Peds2010/><ref name=IDSA2012/>
| deaths = 
}}

<!-- Definition and symptoms -->
'''Streptococcal pharyngitis''', also known as '''streptococcal sore  throat''' ('''strep throat'''), is [[pharyngitis]] (an [[infection]] of the [[pharynx]], the back of the [[throat]]) caused by ''[[Streptococcus pyogenes]]'', a [[Gram-positive bacteria|gram-positive]], [[group A streptococcal infection|group A streptococcus]].<ref name="ICD11">{{cite web |title=ICD-11 for Mortality and Morbidity Statistics |url=https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1642172022 |website=icd.who.int |access-date=21 December 2022}}</ref><ref name="CDC2022">{{cite web |title=Pharyngitis (Strep Throat): Information For Clinicians {{!}} CDC |url=https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html |website=www.cdc.gov |access-date=20 December 2022 |language=en-us |date=19 December 2022}}</ref> Common symptoms include [[fever]], [[sore throat]], red [[Palatine tonsil|tonsils]], and enlarged [[Cervical lymph nodes|lymph nodes]] in the front of the neck. A headache and nausea or vomiting may also occur.<ref name="CDC2022A">{{cite web |title=Is your sore throat strep? |url=https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html |website=Centers for Disease Control and Prevention |access-date=21 December 2022 |language=en-us |date=2 November 2022}}</ref> Some develop a sandpaper-like rash which is known as [[scarlet fever]].<ref name=Tor2011/> Symptoms typically begin one to three days after exposure and last seven to ten days.<ref name=Tor2011/><ref name=Goroll2009>{{cite book |last1=Goroll |first1=Allan H. |first2=Albert G. Jr. |last2=Mulley|title=Primary care medicine: office evaluation and management of the adult patient |date=2009|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins |location=Philadelphia |isbn=978-0-7817-7513-7|page=1408|edition=6th|url=https://books.google.com/books?id=bIZvJPcSEXMC&pg=PA1408 |url-status=live |archive-url=https://web.archive.org/web/20160915085546/https://books.google.com/books?id=bIZvJPcSEXMC&pg=PA1408 |archive-date=2016-09-15}}</ref><ref name="CDC2022A"/>

<!-- Cause and diagnosis -->
Strep throat is spread by [[respiratory droplet]]s from an infected person, spread by talking, coughing or sneezing, or by touching something that has droplets on it and then touching the mouth, nose, or eyes. It may be spread directly through touching infected sores.  It may also be spread by contact with skin infected with group A strep. The diagnosis is made based on the results of a [[rapid antigen detection test]] or [[throat culture]]. Some people may carry the bacteria without symptoms.<ref name="CDC2022A"/>

<!-- Prevention and treatment -->
Prevention is by frequent [[hand washing]], and not sharing eating utensils.<ref name="CDC2022A"/> There is no vaccine for the disease.<ref name=CDC21015/> Treatment with [[antibiotic]]s is only recommended in those with a confirmed diagnosis.<ref name=Ann2016>{{cite journal |last1=Harris |first1=AM |last2=Hicks |first2=LA |last3=Qaseem |first3=A |title=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 |journal=Annals of Internal Medicine |date=19 January 2016 |pmid=26785402 |doi=10.7326/M15-1840 |volume=164|issue=6|pages=425–34|doi-access=free}}</ref> Those infected should stay away from other people until fever is gone and for at least 12 hours after starting treatment.<ref name=CDC21015>{{cite web|title=Is It Strep Throat?|url=https://www.cdc.gov/Features/StrepThroat/ |publisher=CDC|access-date=2 February 2016|date=October 19, 2015 |url-status=live|archive-url=https://web.archive.org/web/20160202151149/http://www.cdc.gov/features/strepthroat/ |archive-date=2 February 2016}}</ref> Pain can be treated with [[paracetamol]] (acetaminophen) and [[nonsteroidal anti-inflammatory drug]]s (NSAIDs) such as [[ibuprofen]].<ref name=Web2014>{{cite journal |last1=Weber |first1=R|title=Pharyngitis |journal=Primary Care |date=March 2014 |volume=41|issue=1|pages=91–8 |pmid=24439883|doi=10.1016/j.pop.2013.10.010 |pmc=7119355}}</ref>

<!-- Epidemiology and prognosis -->
Strep throat is a common bacterial infection in children.<ref name=Tor2011>{{cite book |editor1=David A.Warrell |editor2=Timothy M. Cox |editor3=John D. Firth |editor24=Estée Török |title=Oxford textbook of medicine infection |date=2012|publisher=Oxford University Press |location=Oxford|isbn=978-0-19-163173-3 |pages=280–281|url=https://books.google.com/books?id=qkLibW2ZikYC&pg=PA280|url-status=live |archive-url=https://web.archive.org/web/20161010214543/https://books.google.com/books?id=qkLibW2ZikYC&pg=PA280|archive-date=2016-10-10}}</ref> It is the cause of 15–40% of sore throats among children<ref name=Peds2010>{{cite journal |vauthors=Shaikh N, Leonard E, Martin JM | title = Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis | journal = Pediatrics | volume = 126 | issue = 3 | pages = e557–64 |date=September 2010 | pmid = 20696723 | doi = 10.1542/peds.2009-2648 | s2cid = 8625679 }}</ref><ref name=Review09/> and 5–15% among adults.<ref name=IDSA2012>{{cite journal|last=Shulman|first=ST|author2=Bisno, AL |author3=Clegg, HW |author4=Gerber, MA |author5=Kaplan, EL |author6=Lee, G |author7=Martin, JM |author8= Van Beneden, C |title=Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America.|journal=Clinical Infectious Diseases|date=Sep 9, 2012|pmid=22965026|doi=10.1093/cid/cis629|volume=55|issue=10|pages=e86–102|pmc=7108032|doi-access=free}}</ref> Cases are more common in late winter and early spring.<ref name=Review09>{{cite journal | author = Choby BA | title = Diagnosis and treatment of streptococcal pharyngitis | journal = Am Fam Physician | volume = 79 | issue = 5 | pages = 383–90 | date = March 2009 | pmid = 19275067 | url = http://www.aafp.org/afp/2009/0301/p383.html | url-status = live | archive-url = https://web.archive.org/web/20150208124744/http://www.aafp.org/afp/2009/0301/p383.html | archive-date = 2015-02-08 }}</ref> Potential complications include [[rheumatic fever]] and [[peritonsillar abscess]].<ref name=CDC21015/><ref name=Tor2011/>

==Signs and symptoms==
The typical signs and symptoms of streptococcal pharyngitis are a [[sore throat]], [[fever]] of greater than {{convert|38|C|F}}, tonsillar exudates ([[pus]] on the [[tonsils]]), and large [[cervical lymph nodes]].<ref name=Review09/>

Other symptoms include: [[headache]], [[nausea]] and [[vomiting]], [[abdominal pain]],<ref name=Review06>{{cite journal |vauthors=Brook I, Dohar JE | title = Management of group A beta-hemolytic streptococcal pharyngotonsillitis in children | journal = J Fam Pract | volume = 55 | issue = 12 |pages = S1–11; quiz S12 |date=December 2006 | pmid = 17137534 }}</ref> [[myalgia|muscle pain]],<ref name=Review2001/> or a [[scarlatiniform rash]] or [[palatal petechiae]], the latter being an uncommon but highly [[Sensitivity and specificity|specific]] finding.<ref name=Review09/>

Symptoms typically begin one to three days after exposure and last seven to ten days.<ref name=Goroll2009/><ref name=Review09/>

Strep throat is unlikely when any of the symptoms of [[conjunctivitis|red eyes]], hoarseness, runny nose, or mouth ulcers are present. It is also unlikely when there is no fever.<ref name=IDSA2012/>

<gallery class="center" caption="" widths="200px" heights="175px">
File:StrepAug2010.JPG|Mouth wide open showing the throat<br />A throat infection which on culture tested positive for group A streptococcus. Note the large tonsils with white [[exudate]].
File:Streptococcal pharyngitis.jpg|Mouth wide open showing the throat<br />Note the [[petechiae]], or small red spots, on the [[soft palate]]. This is an uncommon but highly [[Sensitivity and specificity|specific]] finding in streptococcal pharyngitis.<ref name=Review09/>
File:Strep throat2010.JPG|A set of large tonsils in the back of the throat, covered in white exudate.<br />This is a culture-positive case of streptococcal pharyngitis with typical tonsillar exudate in an 8-year-old.
<!--|lines is number of lines needed for biggest caption -->
</gallery>

==Cause==
Strep throat is caused by [[group A beta-hemolytic streptococcus|group A β-hemolytic ''Streptococcus'']] (GAS or ''S. pyogenes'').<ref name=Review10>{{cite journal | author = Baltimore RS | title = Re-evaluation of antibiotic treatment of streptococcal pharyngitis | journal = Curr. Opin. Pediatr. | volume = 22 | issue = 1 | pages = 77–82 |date=February 2010 | pmid = 19996970 | doi = 10.1097/MOP.0b013e32833502e7 | s2cid = 13141765 }}</ref> Humans are the primary natural reservoir for group A streptococcus.<ref>{{Cite web|date=2019-04-19|title=Group A Strep|url=https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html|url-status=live|archive-url=https://web.archive.org/web/20201027072216/https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html|archive-date=2020-10-27|access-date=2020-10-27|website=[[Centers for Disease Control and Prevention|U. S. Centers for Disease Control and Prevention]]|publisher=[[United States Department of Health and Human Services|U. S. Department of Health & Human Services]]|language=en-us}}</ref> Other bacteria such as [[non–group A beta-hemolytic streptococci|non–group A β-hemolytic ''streptococci'']] and ''[[fusobacterium]]'' may also cause [[pharyngitis]].<ref name=Review09/><ref name=Review2001/>  It is spread by direct, close contact with an infected person; thus crowding, as may be found in the military and schools, increases the rate of transmission.<ref name=Review2001>{{cite journal | vauthors = Hayes CS, Williamson H | title = Management of Group A beta-hemolytic streptococcal pharyngitis | journal = Am Fam Physician | volume = 63 | issue = 8 | pages = 1557–64 | date = April 2001 | pmid = 11327431 | url = http://www.aafp.org/afp/20010415/1557.html | url-status = live | archive-url = https://web.archive.org/web/20080516091711/http://www.aafp.org/afp/20010415/1557.html | archive-date = 2008-05-16 }}</ref><ref name="pmid15765640">{{cite journal |vauthors=Lindbaek M, Høiby EA, Lermark G, Steinsholt IM, Hjortdahl P | title = Predictors for spread of clinical group A streptococcal tonsillitis within the household | journal = Scand J Prim Health Care | volume = 22 | issue = 4 | pages = 239–43 | year = 2004 | pmid = 15765640 | doi = 10.1080/02813430410006729 | doi-access = free }}</ref>  Dried bacteria in dust are not infectious, although moist bacteria on toothbrushes or similar items can persist for up to fifteen days.<ref name=Review2001/>  Contaminated food can result in outbreaks, but this is rare.<ref name=Review2001/>  Of children with no signs or symptoms, 12% carry GAS in their pharynx,<ref name=Peds2010/> and, after treatment, approximately 15% of those remain positive, and are true "carriers".<ref>{{cite book|editor1=Robert E. Rakel|editor2=David P. Rakel|title=Textbook of family medicine|publisher=Elsevier Saunders|location=Philadelphia, PA.|isbn=978-1-4377-1160-8|page=331|url=https://books.google.com/books?id=t0Mh0yOH5EsC&pg=PA331|edition=8th|year=2011|url-status=live|archive-url=https://web.archive.org/web/20170908183611/https://books.google.com/books?id=t0Mh0yOH5EsC&pg=PA331|archive-date=2017-09-08}}</ref>

==Diagnosis==
{| class="wikitable" style = "float: right; margin-left:15px; text-align:center"
|+ Modified Centor score
!Points||Probability of Strep||Management
|-
| 1 or fewer|| <10%||No antibiotic or culture needed
|-
| 2        ||11–17%||rowspan="2"|Antibiotic based on culture or RADT
|-
| 3        ||28–35%
|-
| 4 or 5   ||52%||[[Empiric antibiotics]]
|}

A number of scoring systems exist to help with diagnosis; however, their use is controversial due to insufficient accuracy.<ref>{{cite journal|last1=Cohen|first1=JF|last2=Cohen|first2=R|last3=Levy|first3=C|last4=Thollot|first4=F|last5=Benani|first5=M|last6=Bidet|first6=P|last7=Chalumeau|first7=M|title=Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study.|journal=Canadian Medical Association Journal |date=6 January 2015|volume=187|issue=1|pages=23–32|pmid=25487666|doi=10.1503/cmaj.140772|pmc=4284164}}</ref> The modified [[Centor criteria]] are a set of five criteria; the total score indicates the probability of a streptococcal infection.<ref name=Review09/>

One point is given for each of the criteria:<ref name=Review09/>
*Absence of a cough
*Swollen and tender cervical lymph nodes
*Temperature >{{convert|38.0|C|F}}
*Tonsillar exudate or swelling
*Age less than 15 (a point is subtracted if age >44)

A score of one may indicate no treatment or culture is needed or it may indicate the need to perform further testing if other high risk factors exist, such as a family member having the disease.<ref name=Review09/>

The [[Infectious Disease Society of America]] recommends against routine antibiotic treatment and considers antibiotics only appropriate when given after a positive test.<ref name="IDSA2012" /> Testing is not needed in children under three as both group A strep and [[rheumatic fever]] are rare, unless a child has a sibling with the disease.<ref name="IDSA2012" />

===Laboratory testing===
A [[throat culture]] is the [[gold standard (test)|gold standard]]<ref>{{Cite book|author1=Smith, Ellen Reid |author2=Kahan, Scott |author3=Miller, Redonda G. |title=In A Page Signs & Symptoms |series=In a Page Series |publisher=Lippincott Williams & Wilkins |location=Hagerstown, Maryland |year=2008 |page=312 |isbn=978-0-7817-7043-9 }}</ref> for the diagnosis of streptococcal pharyngitis, with a sensitivity of 90–95%.<ref name=Review09/>  A [[rapid strep test]] (also called rapid antigen detection testing or RADT) may also be used. While the rapid strep test is quicker, it has a lower [[sensitivity (tests)|sensitivity]] (70%) and statistically equal [[specificity (tests)|specificity]] (98%) as a throat culture.<ref name=Review09/> In areas of the world where [[rheumatic fever]] is uncommon, a negative rapid strep test is sufficient to rule out the disease.<ref>{{cite journal|last1=Lean|first1=WL|last2=Arnup|first2=S|last3=Danchin|first3=M|last4=Steer|first4=AC|title=Rapid diagnostic tests for group A streptococcal pharyngitis: a meta-analysis.|journal=Pediatrics|date=October 2014|volume=134|issue=4|pages=771–81|pmid=25201792|doi=10.1542/peds.2014-1094|s2cid=15909263}}</ref>

A positive throat culture or RADT in association with symptoms establishes a positive diagnosis in those in which the diagnosis is in doubt.<ref name=IDSAGuideline2002/> In adults, a negative RADT is sufficient to rule out the diagnosis. However, in children a throat culture is recommended to confirm the result.<ref name=IDSA2012/> Asymptomatic individuals should not be routinely tested with a throat culture or RADT because a certain percentage of the population persistently "carries" the streptococcal bacteria in their throat without any harmful results.<ref name=IDSAGuideline2002/>

===Differential diagnosis===
{{See also|Acute pharyngitis}}
As the symptoms of streptococcal pharyngitis overlap with other conditions, it can be difficult to make the diagnosis clinically.<ref name=Review09/> Coughing, nasal discharge, [[diarrhea]], and [[conjunctivitis|red, irritated eyes]] in addition to fever and sore throat are more indicative of a [[viral sore throat]] than of strep throat.<ref name=Review09/> The presence of marked lymph node enlargement along with sore throat, fever, and tonsillar enlargement may also occur in [[infectious mononucleosis]].<ref name="pmid15508538">{{cite journal | author = Ebell MH | title = Epstein-Barr virus infectious mononucleosis | journal = Am Fam Physician | volume = 70 | issue = 7 | pages = 1279–87 | year = 2004 | pmid = 15508538 | url = http://www.aafp.org/afp/20041001/1279.html | url-status = live | archive-url = https://web.archive.org/web/20080724055725/http://www.aafp.org/afp/20041001/1279.html | archive-date = 2008-07-24 }}</ref> Other conditions that may present similarly include [[epiglottitis]], [[Kawasaki disease]], [[acute retroviral syndrome]], [[Lemierre's syndrome]], [[Ludwig's angina]], [[peritonsillar abscess]], and [[retropharyngeal abscess]].<ref name=Got2018>{{cite journal |last1=Gottlieb |first1=M |last2=Long |first2=B |last3=Koyfman |first3=A |title=Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. |journal=The Journal of Emergency Medicine |date=May 2018 |volume=54 |issue=5 |pages=619–629 |doi=10.1016/j.jemermed.2018.01.031 |pmid=29523424|doi-access=free }}</ref>

==Prevention==
[[Tonsillectomy]] may be a reasonable preventive measure in those with frequent throat infections (more than three a year).<ref>{{cite journal |vauthors=Johnson BC, Alvi A | title = Cost-effective workup for tonsillitis. Testing, treatment, and potential complications | journal = Postgrad Med | volume = 113 | issue = 3 | pages = 115–8, 121 |date=March 2003 | pmid = 12647478 | doi =  10.3810/pgm.2003.03.1391| s2cid = 33329630 }}</ref> However, the benefits are small and episodes typically lessen in time regardless of measures taken.<ref>{{cite journal|vauthors=van Staaij BK, van den Akker EH, van der Heijden GJ, Schilder AG, Hoes AW |title=Adenotonsillectomy for upper respiratory infections: evidence based?|journal=Archives of Disease in Childhood|date=January 2005|volume=90|issue=1|pages=19–25|pmid=15613505|doi=10.1136/adc.2003.047530|pmc=1720065}}</ref><ref>{{cite journal|last1=Burton|first1=MJ|last2=Glasziou|first2=PP|last3=Chong|first3=LY|last4=Venekamp|first4=RP|title=Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis.|journal=The Cochrane Database of Systematic Reviews|date=19 November 2014|volume=2014 |issue=11|article-number=CD001802|pmid=25407135|doi=10.1002/14651858.CD001802.pub3|pmc=7075105|url=https://pure.bond.edu.au/ws/files/32844113/Tonsillectomy_or_adenotonsillectomy_versus_non_surgical_treatment_for_chronic.pdf |archive-url=https://ghostarchive.org/archive/20221010/https://pure.bond.edu.au/ws/files/32844113/Tonsillectomy_or_adenotonsillectomy_versus_non_surgical_treatment_for_chronic.pdf |archive-date=2022-10-10 |url-status=live}}</ref><ref>{{cite journal|last1=Morad|first1=Anna|last2=Sathe|first2=Nila A.|last3=Francis|first3=David O.|last4=McPheeters|first4=Melissa L.|last5=Chinnadurai|first5=Sivakumar|title=Tonsillectomy Versus Watchful Waiting for Recurrent Throat Infection: A Systematic Review|journal=Pediatrics|date=17 January 2017|pages=e20163490|doi=10.1542/peds.2016-3490|url= http://pediatrics.aappublications.org/content/early/2017/01/15/peds.2016-3490?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token|language=en|issn=0031-4005|volume=139|issue=2|pmid=28096515|pmc=5260157|url-status=live|archive-url=https://web.archive.org/web/20170813012822/http://pediatrics.aappublications.org/content/early/2017/01/15/peds.2016-3490?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token|archive-date=13 August 2017}}</ref> Recurrent episodes of pharyngitis which test positive for GAS may also represent a person who is a chronic carrier of GAS who is getting recurrent viral infections.<ref name=IDSA2012/> Treating people who have been exposed but who are without symptoms is not recommended.<ref name=IDSA2012/> Treating people who are carriers of GAS is not recommended as the risk of spread and complications is low.<ref name=IDSA2012/>

==Treatment==
Untreated streptococcal pharyngitis usually resolves within a few days.<ref name=Review09/> Treatment with antibiotics shortens the duration of the acute illness by about 16&nbsp;hours.<ref name=Review09/> The primary reason for treatment with antibiotics is to reduce the risk of complications such as [[rheumatic fever]] and [[retropharyngeal abscess]]es.<ref name=Review09/> Antibiotics prevent acute rheumatic fever if given within 9 days of the onset of symptoms.<ref name=Review10/>

===Pain medication===
Pain medication such as NSAIDs and [[paracetamol]] (acetaminophen) helps in the management of pain associated with strep throat.<ref name=Review00>{{cite journal |vauthors=Thomas M, Del Mar C, Glasziou P | title = How effective are treatments other than antibiotics for acute sore throat? | journal = Br J Gen Pract | volume = 50 | issue = 459 | pages = 817–20 |date=October 2000 | pmid = 11127175 | pmc = 1313826 }}</ref> Viscous [[lidocaine]] may also be useful.<ref>{{Cite web |url=http://www.medicinenet.com/lidocaine_viscous/article.htm |title=Generic Name: Lidocaine Viscous (Xylocaine Viscous) side effects, medical uses, and drug interactions |work=MedicineNet.com |access-date=2010-05-07 |url-status=live |archive-url=https://web.archive.org/web/20100408065631/http://www.medicinenet.com/lidocaine_viscous/article.htm |archive-date=2010-04-08 }}</ref> While [[steroids]] may help with the pain,<ref name=Review10/><ref>{{cite journal|last=Wing|first=A|author2=Villa-Roel, C |author3=Yeh, B |author4=Eskin, B |author5=Buckingham, J |author6= Rowe, BH |title=Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature.|journal=Academic Emergency Medicine|date=May 2010|volume=17|issue=5|pages=476–83|pmid=20536799|doi=10.1111/j.1553-2712.2010.00723.x|s2cid=24555114|doi-access=free}}</ref> they are not routinely recommended.<ref name=IDSA2012/> Aspirin may be used in adults but is not recommended in children due to the risk of [[Reye syndrome]].<ref name=Review10/>

===Antibiotics===
The antibiotic of choice in the United States for streptococcal pharyngitis is [[Phenoxymethylpenicillin|penicillin V]], due to safety, cost, and effectiveness.<ref name=Review09/> [[Amoxicillin]] is preferred in Europe.<ref>{{cite journal |vauthors=Bonsignori F, Chiappini E, De Martino M | title = The infections of the upper respiratory tract in children | journal = Int J Immunopathol Pharmacol | volume = 23 | issue = 1 Suppl | pages = 16–9 | year = 2010 | doi = 10.1177/03946320100230S105 | pmid = 20152073 | s2cid = 7272884 }}</ref> In India, where the risk of rheumatic fever is higher, intramuscular [[benzathine benzylpenicillin|benzathine penicillin]] G is the first choice for treatment.<ref name=Review10/>

Appropriate antibiotics decrease the average 3–5 day duration of symptoms by about one day, and also reduce contagiousness.<ref name="IDSAGuideline2002" /> They are primarily prescribed to reduce rare complications such as [[rheumatic fever]] and [[peritonsillar abscess]].<ref name="InternalMedPosition2001">{{cite journal | vauthors = Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR | title = Principles of appropriate antibiotic use for acute pharyngitis in adults | journal = Ann Intern Med | volume = 134 | issue = 6 | pages = 506–8 | date = March 2001 | pmid = 11255529 | doi = 10.7326/0003-4819-134-6-200103200-00018 | s2cid = 35082591 }}{{Update inline|?=yes|date=September 2016}}</ref> The arguments in favor of antibiotic treatment should be balanced by the consideration of possible side effects,<ref name="Review2001" /> and it is reasonable to suggest that no antimicrobial treatment be given to healthy adults who have adverse reactions to medication or those at low risk of complications.<ref name="InternalMedPosition2001" /><ref name=EB2015>{{cite journal|last1=Hildreth|first1=AF|last2=Takhar|first2=S|last3=Clark|first3=MA|last4=Hatten|first4=B|title=Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department.|journal=Emergency Medicine Practice|date=September 2015|volume=17|issue=9|pages=1–16; quiz 16–7|pmid=26276908}}</ref> Antibiotics are prescribed for strep throat at a higher rate than would be expected from how common it is.<ref>{{cite journal |vauthors=Linder JA, Bates DW, Lee GM, Finkelstein JA | title = Antibiotic treatment of children with sore throat | journal = J Am Med Assoc | volume = 294 | issue = 18 | pages = 2315–22 |date=November 2005 | pmid = 16278359 | doi = 10.1001/jama.294.18.2315 | doi-access = free }}</ref>

[[Erythromycin]] and other [[macrolides]] or [[clindamycin]] are recommended for people with severe [[penicillin allergy|penicillin allergies]].<ref name="Review09" /><ref name="IDSA2012" /> First-generation [[cephalosporins]] may be used in those with less severe allergies<ref name="Review09" /> and some low-certainty evidence suggest cephalosporins are superior to penicillin.<ref>{{cite journal|last=Pichichero|first=M|author2=Casey, J |title=Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis.|journal= [[European Journal of Clinical Microbiology & Infectious Diseases]] |date=June 2006|volume=25|issue=6|pages=354–64|pmid=16767482|doi=10.1007/s10096-006-0154-7|s2cid=839362}}</ref><ref>{{Cite journal |last1=Hedin |first1=Katarina |last2=Thorning |first2=Sarah |last3=van Driel |first3=Mieke L. |date=2023-11-15 |title=Different antibiotic treatments for group A streptococcal pharyngitis |journal=The Cochrane Database of Systematic Reviews |volume=2023 |issue=11 |article-number=CD004406 |doi=10.1002/14651858.CD004406.pub6 |issn=1469-493X |pmc=10646936 |pmid=37965935}}</ref> These late-generation antibiotics show a similar effect when prescribed for 3–7 days in comparison to the standard ten days of penicillin when used in areas of low rheumatic heart disease.<ref>{{cite journal |last1=Altamimi |first1=Saleh |last2=Khalil |first2=Adli |last3=Khalaiwi |first3=Khalid A |last4=Milner |first4=Ruth A |last5=Pusic |first5=Martin V |last6=Al Othman |first6=Mohammed A |title=Short-term late-generation antibiotics versus longer term penicillin for acute streptococcal pharyngitis in children |journal=Cochrane Database of Systematic Reviews |date=15 August 2012 |issue=8 |article-number=CD004872 |doi=10.1002/14651858.CD004872.pub3|pmid=22895944 |pmc=11984625 }}</ref> Streptococcal infections may also lead to [[acute glomerulonephritis]]; however, the incidence of this side effect is not reduced by the use of antibiotics.<ref name="Review10" />

==Prognosis==
The symptoms of strep throat usually improve within three to five days, irrespective of treatment.<ref name=IDSAGuideline2002>{{cite journal |vauthors=Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH | title = Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America | journal = Clin. Infect. Dis. | volume = 35 | issue = 2 | pages = 113–25 |date=July 2002 | pmid = 12087516 | doi = 10.1086/340949 | url = https://academic.oup.com/cid/article-pdf/35/2/113/13141808/35-2-113.pdf | doi-access = free }}</ref> Treatment with antibiotics reduces the risk of complications and transmission; children may return to school 24 hours after antibiotics are administered.<ref name=Review09/> The risk of complications in adults is low.<ref name=IDSA2012/> In children, acute rheumatic fever is rare in most of the developed world. It is, however, the leading cause of acquired heart disease in India, sub-Saharan Africa, and some parts of Australia.<ref name=IDSA2012/>

==Complications==
Complications arising from streptococcal throat infections include:
{{colbegin}} 
* [[Rheumatic fever|Acute rheumatic fever]]<ref name=Review06/>
* [[Scarlet fever]]<ref name=Uptodate/>
* [[Toxic shock syndrome|Streptococcal toxic shock syndrome]]<ref name=Uptodate>{{Cite web |url=http://www.utdol.com/online/content/topic.do?topicKey=upp_resp/4610 |title=UpToDate Inc. |url-status=live |archive-url=https://web.archive.org/web/20081208133138/http://www.utdol.com/online/content/topic.do?topicKey=upp_resp%2F4610 |archive-date=2008-12-08 }}</ref><ref>{{cite journal  |vauthors=Stevens DL, Tanner MH, Winship J, etal | title = Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A | journal = N. Engl. J. Med. | volume = 321 | issue = 1 | pages = 1–7 |date=July 1989 | pmid = 2659990 | doi = 10.1056/NEJM198907063210101 }}</ref>
* [[Glomerulonephritis]]<ref name=Review05>{{cite journal |vauthors=Hahn RG, Knox LM, Forman TA | title = Evaluation of poststreptococcal illness | journal = Am Fam Physician | volume = 71 | issue = 10 | pages = 1949–54 |date=May 2005 | pmid = 15926411 }}</ref>
* [[PANDAS|PANDAS syndrome]]<ref name= Wilbur2019>{{cite journal |vauthors=Wilbur C, Bitnun A, Kronenberg S, Laxer RM, Levy DM, Logan WJ, Shouldice M, Yeh EA |title=PANDAS/PANS in childhood: Controversies and evidence |journal=Paediatr Child Health |volume=24 |issue=2 |pages=85–91 |date=May 2019 |pmid=30996598 |pmc=6462125 |doi=10.1093/pch/pxy145}}</ref><ref name=Sigra2018>{{cite journal |vauthors=Sigra S, Hesselmark E, Bejerot S |title=Treatment of PANDAS and PANS: a systematic review |journal=Neurosci Biobehav Rev |volume=86 |issue= |pages=51–65 |date=March 2018 |pmid=29309797 |doi=10.1016/j.neubiorev.2018.01.001 |s2cid=40827012 |doi-access=free }}</ref><ref name=Moretti2008>{{Cite journal|vauthors=Moretti G, Pasquini M, Mandarelli G, Tarsitani L, Biondi M |title=What every psychiatrist should know about PANDAS: a review |journal=Clin Pract Epidemiol Ment Health |volume=4|issue=1 |page=13 |year=2008 |pmid=18495013 |pmc=2413218 |doi=10.1186/1745-0179-4-13 |doi-access=free }}</ref> 
* [[Peritonsillar abscess]]<ref name=IDSA2012/> 
*[[Cervical lymphadenitis]]<ref name=IDSA2012/> 
*[[Mastoiditis]]<ref name=IDSA2012/> 
{{colend}}

The economic cost of the disease in the United States in children is approximately $350 million annually.<ref name=IDSA2012/>

==Epidemiology==
[[Pharyngitis]], the broader category into which Streptococcal pharyngitis falls, is diagnosed in 11 million people annually in the United States.<ref name=Review09/> It is the cause of 15–40% of sore throats among children<ref name=Peds2010/><ref name=Review09/> and 5–15% in adults.<ref name=IDSA2012/> Cases usually occur in late winter and early spring.<ref name=Review09/>

==References==
{{Reflist}}

==External links==
{{offline|med}}
{{Medical condition classification and resources
 | DiseasesDB     = 12507
 | ICD11          = {{ICD10|J|02|0|j|00}}
 | ICD10          = {{ICD10|J|02|0|j|00}}
 | ICD9           = {{ICD9|034.0}}
 | ICDO           =
 | OMIM           =
 | MedlinePlus    = 000639
 | eMedicineSubj  = med
 | eMedicineTopic = 1811
 | MeshID         =
}}
{{Respiratory pathology}}

{{DEFAULTSORT:Streptococcal Pharyngitis}}
[[Category:Acute upper respiratory infections]]
[[Category:Human throat]]
[[Category:Wikipedia medicine articles ready to translate (full)]]
[[Category:Wikipedia emergency medicine articles ready to translate]]
[[Category:Streptococcal infections]]