Management of Chronic Strep Infections

Introduction to Chronic Strep

The American Academy of Pediatrics and the Infectious Diseases Society of America recommend that chronic pharyngeal carriers with Group A Streptococcus (GAS) do not ordinarily require antimicrobial therapy, as they are unlikely to spread the organism to close contacts and are at very low risk for developing complications like acute rheumatic fever 1
The Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) define recurrent acute streptococcal pharyngitis as multiple true infections requiring standard treatment with each episode, which is distinct from chronic pharyngeal carriage 1

The American College of Physicians and the Infectious Diseases Society of America recommend penicillin or amoxicillin as the drug of choice for streptococcal pharyngitis due to proven efficacy, narrow spectrum, safety, and low cost, with no documented penicillin resistance in GAS anywhere in the world 2, 3
The American Academy of Pediatrics recommends clindamycin as the optimal choice for chronic carriers requiring eradication therapy, with demonstrated 100% eradication rates in patients who failed penicillin therapy, and a low resistance rate of ~1% among GAS in the United States 1, 2, 4

The Infectious Diseases Society of America recommends clindamycin 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days in children, or 300 mg three times daily for 10 days in adults, for chronic carriers requiring eradication therapy 1, 2
Alternative regimens for carrier eradication include penicillin V plus rifampin, amoxicillin-clavulanate, and benzathine penicillin G plus rifampin, as recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America 1

The American College of Physicians and the Infectious Diseases Society of America recommend penicillin V 250 mg three or four times daily OR 500 mg twice daily for 10 days in adults, or amoxicillin for young children, as first-line treatment for acute streptococcal pharyngitis 3
For penicillin-allergic patients, the American Academy of Pediatrics recommends non-immediate allergy treatment with first-generation cephalosporins, and immediate/anaphylactic allergy treatment with clindamycin or azithromycin, due to the risk of cross-reactivity and resistance 2, 3

The Infectious Diseases Society of America and the American Academy of Pediatrics recommend a full 10-day course of antibiotics (except azithromycin's 5-day regimen) to achieve maximal pharyngeal eradication of GAS and prevent acute rheumatic fever, as shortening the course increases treatment failure rates and rheumatic fever risk 1, 2, 3