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Treatment and prevention of streptococcal pharyngitis

Michael E Pichichero, MD
Section Editors
Daniel J Sexton, MD
Morven S Edwards, MD
Deputy Editor
Sheila Bond, MD


Group A Streptococcus (GAS), or Streptococcus pyogenes, is the leading bacterial cause of tonsillopharyngitis in adults and children worldwide. GAS is one of the few causes of tonsillopharyngitis or pharyngitis for which antibiotic treatment is recommended.

The treatment and prevention of group A streptococcal tonsillopharyngitis is reviewed here. The clinical features and diagnostic evaluation of patients with tonsillopharyngitis are discussed separately. (See "Group A streptococcal tonsillopharyngitis in children and adolescents: Clinical features and diagnosis" and "Evaluation of acute pharyngitis in adults".)


Group A Streptococcus (GAS) can cause symptomatic infection or can colonize the oropharynx.

Active infection refers to symptomatic infection caused by GAS.

Persistent infection refers to symptomatic infection caused by GAS that does not resolve after appropriate antibiotic treatment. This is synonymous with treatment failure.

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Literature review current through: Nov 2017. | This topic last updated: Dec 11, 2017.
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  1. Efstratiou A, Lamagni T. Epidemiology of Streptococcus pyogenes. In: Streptococcus pyogenes: Basic Biology to Clinical Manifestations, Ferretti JJ, Stevens DL, Fischetti VA (Eds), University of Oklahoma Health Sciences Center, Oklahoma City 2016.
  2. Gunnarsson RK, Holm SE, Söderström M. The prevalence of beta-haemolytic streptococci in throat specimens from healthy children and adults. Implications for the clinical value of throat cultures. Scand J Prim Health Care 1997; 15:149.
  3. Schwartz RH, Wientzen RL Jr, Pedreira F, et al. Penicillin V for group A streptococcal pharyngotonsillitis. A randomized trial of seven vs ten days' therapy. JAMA 1981; 246:1790.
  4. Pontin IP, Sanchez DC, Di Francesco R. Asymptomatic Group A Streptococcus carriage in children with recurrent tonsillitis and tonsillar hypertrophy. Int J Pediatr Otorhinolaryngol 2016; 86:57.
  5. Abdissa A, Asrat D, Kronvall G, et al. Throat carriage rate and antimicrobial susceptibility pattern of group A Streptococci (GAS) in healthy Ethiopian school children. Ethiop Med J 2011; 49:125.
  6. Nayiga I, Okello E, Lwabi P, Ndeezi G. Prevalence of group a streptococcus pharyngeal carriage and clinical manifestations in school children aged 5-15 yrs in Wakiso District, Uganda. BMC Infect Dis 2017; 17:248.
  7. Marshall HS, Richmond P, Nissen M, et al. Group A Streptococcal Carriage and Seroepidemiology in Children up to 10 Years of Age in Australia. Pediatr Infect Dis J 2015; 34:831.
  8. Martin JM, Green M, Barbadora KA, Wald ER. Group A streptococci among school-aged children: clinical characteristics and the carrier state. Pediatrics 2004; 114:1212.
  9. Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics 2010; 126:e557.
  10. Kaplan EL. The group A streptococcal upper respiratory tract carrier state: an enigma. J Pediatr 1980; 97:337.
  11. Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst Rev 2013; :CD000023.
  12. Little P, Hobbs FD, Moore M, et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). BMJ 2013; 347:f5806.
  13. BRINK WR, RAMMELKAMP CH Jr, DENNY FW, WANNAMAKER LW. Effect in penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis. Am J Med 1951; 10:300.
  14. Roth GA, Huffman MD, Moran AE, et al. Global and regional patterns in cardiovascular mortality from 1990 to 2013. Circulation 2015; 132:1667.
  15. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis 2005; 5:685.
  16. Beaudoin A, Edison L, Introcaso CE, et al. Acute rheumatic fever and rheumatic heart disease among children--American Samoa, 2011-2012. MMWR Morb Mortal Wkly Rep 2015; 64:555.
  17. Brundage JF, Gunzenhauser JD, Longfield JN, et al. Epidemiology and control of acute respiratory diseases with emphasis on group A beta-hemolytic streptococcus: a decade of U.S. Army experience. Pediatrics 1996; 97:964.
  18. BREESE BB, DISNEY FA. Factors influencing the spread of beta hemolytic streptococcal infections within the family group. Pediatrics 1956; 17:834.
  19. Lamagni TL, Oliver I, Stuart JM. Global assessment of invasive group a streptococcus infection risk in household contacts. Clin Infect Dis 2015; 60:166.
  20. Snellman LW, Stang HJ, Stang JM, et al. Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics 1993; 91:1166.
  21. Schwartz RH, Kim D, Martin M, Pichichero ME. A Reappraisal of the Minimum Duration of Antibiotic Treatment Before Approval of Return to School for Children With Streptococcal Pharyngitis. Pediatr Infect Dis J 2015; 34:1302.
  22. WANNAMAKER LW, RAMMELKAMP CH Jr, DENNY FW, et al. Prophylaxis of acute rheumatic fever by treatment of the preceding streptococcal infection with various amounts of depot penicillin. Am J Med 1951; 10:673.
  23. 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; 55:1279.
  24. Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. 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; 164:425.
  25. 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; 119:1541.
  26. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Thorac Cardiovasc Surg 2014; 148:e1.
  27. American Academy of Pediatrics. Group A Streptococcus. In: Red Book: 2015 Report of the Committee of Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2018. p.732.
  28. ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, et al. Guideline for the management of acute sore throat. Clin Microbiol Infect 2012; 18 Suppl 1:1.
  29. The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition) https://www.rhdaustralia.org.au/sites/default/files/resources/guideline_0_0.pdf (Accessed on October 27, 2017).
  30. New Zealand Guidelines for Rheumatic Fever. Group A Streptococcal Sore Throat Management Guideline: 2014 Update http://assets.heartfoundation.org.nz/shop/heart-healthcare/non-stock-resources/gas-sore-throat-rheumatic-fever-guideline.pdf (Accessed on October 27, 2017).
  31. Gopichand I, Williams GD, Medendorp SV, et al. Randomized, single-blinded comparative study of the efficacy of amoxicillin (40 mg/kg/day) versus standard-dose penicillin V in the treatment of group A streptococcal pharyngitis in children. Clin Pediatr (Phila) 1998; 37:341.
  32. Curtin-Wirt C, Casey JR, Murray PC, et al. Efficacy of penicillin vs. amoxicillin in children with group A beta hemolytic streptococcal tonsillopharyngitis. Clin Pediatr (Phila) 2003; 42:219.
  33. Lennon DR, Farrell E, Martin DR, Stewart JM. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child 2008; 93:474.
  34. Feder HM Jr, Gerber MA, Randolph MF, et al. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics 1999; 103:47.
  35. Clegg HW, Ryan AG, Dallas SD, et al. Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin: a noninferiority trial. Pediatr Infect Dis J 2006; 25:761.
  36. Kaplan EL, Gooch III WM, Notario GF, Craft JC. 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; 32:1798.
  37. Altamimi S, Khalil A, Khalaiwi KA, et al. Short-term late-generation antibiotics versus longer term penicillin for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev 2012; :CD004872.
  38. WANNAMAKER LW, DENNY FW, PERRY WD, et al. The effect of penicillin prophylaxis on streptococcal disease rates and the carrier state. N Engl J Med 1953; 249:1.
  39. Gerber MA, Randolph MF, Chanatry J, et al. Five vs ten days of penicillin V therapy for streptococcal pharyngitis. Am J Dis Child 1987; 141:224.
  40. BREESE BB, DISNEY FA. Penicillin in the treatment of streptococcal infections; a comparison of effectiveness of five different oral and one parenteral form. N Engl J Med 1958; 259:57.
  41. Tack KJ, Henry DC, Gooch WM, et al. Five-day cefdinir treatment for streptococcal pharyngitis. Cefdinir Pharyngitis Study Group. Antimicrob Agents Chemother 1998; 42:1073.
  42. Pichichero ME, Gooch WM 3rd. Comparison of cefdinir and penicillin V in the treatment of pediatric streptococcal tonsillopharyngitis. Pediatr Infect Dis J 2000; 19:S171.
  43. 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; 148:1053.
  44. Tack KJ, Hedrick JA, Rothstein E, et al. A study of 5-day cefdinir treatment for streptococcal pharyngitis in children. Cefdinir Pediatric Pharyngitis Study Group. Arch Pediatr Adolesc Med 1997; 151:45.
  45. van Driel ML, De Sutter AI, Habraken H, et al. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev 2016; 9:CD004406.
  46. Richter SS, Heilmann KP, Beekmann SE, et al. Macrolide-resistant Streptococcus pyogenes in the United States, 2002-2003. Clin Infect Dis 2005; 41:599.
  47. Lin JN, Chang LL, Lai CH, et al. High prevalence of fluoroquinolone-nonsusceptible Streptococcus pyogenes emm12 in Taiwan. Diagn Microbiol Infect Dis 2015; 83:187.
  48. Petrelli D, Di Luca MC, Prenna M, et al. Characterization of levofloxacin non-susceptible clinical Streptococcus pyogenes isolated in the central part of Italy. Eur J Clin Microbiol Infect Dis 2014; 33:241.
  49. Van Heirstraeten L, Leten G, Lammens C, et al. Increase in fluoroquinolone non-susceptibility among clinical Streptococcus pyogenes in Belgium during 2007-10. J Antimicrob Chemother 2012; 67:2602.
  50. Palmieri C, Vecchi M, Littauer P, et al. Clonal spread of macrolide- and tetracycline-resistant [erm(A) tet(O)] emm77 Streptococcus pyogenes isolates in Italy and Norway. Antimicrob Agents Chemother 2006; 50:4229.
  51. Michos AG, Bakoula CG, Braoudaki M, et al. Macrolide resistance in Streptococcus pyogenes: prevalence, resistance determinants, and emm types. Diagn Microbiol Infect Dis 2009; 64:295.
  52. FDA Drug Safety Communication; May 12, 2016 https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm (Accessed on September 11, 2017).
  53. Randolph MF, Gerber MA, DeMeo KK, Wright L. Effect of antibiotic therapy on the clinical course of streptococcal pharyngitis. J Pediatr 1985; 106:870.
  54. Pichichero ME, Disney FA, Talpey WB, et al. Adverse and beneficial effects of immediate treatment of Group A beta-hemolytic streptococcal pharyngitis with penicillin. Pediatr Infect Dis J 1987; 6:635.
  55. Krober MS, Bass JW, Michels GN. Streptococcal pharyngitis. Placebo-controlled double-blind evaluation of clinical response to penicillin therapy. JAMA 1985; 253:1271.
  56. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2000; :CD000023.
  57. Gilbert GG, Pruitt BE. School health education in the United States. Hygie 1984; 3:10.
  58. 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; 98:326.
  59. Woodin KA, Lee LH, Pichichero ME. Milder symptoms occur in recurrent episodes of streptococcal infection. Am J Dis Child 1991; 145:389.
  60. Pichichero ME, Hoeger W, Marsocci SM, et al. Variables influencing penicillin treatment outcome in streptococcal tonsillopharyngitis. Arch Pediatr Adolesc Med 1999; 153:565.
  61. Cohen JF, Bertille N, Cohen R, Chalumeau M. Rapid antigen detection test for group A streptococcus in children with pharyngitis. Cochrane Database Syst Rev 2016; 7:CD010502.
  62. Yildirim I, Ceyhan M, Gür D, Kaymakoğlu I. Comparison of the effect of benzathine penicillin G, clarithromycin, cefprozil and amoxicillin/clavulanate on the bacteriological response and throat flora in group A beta hemolytic streptococcal tonsillopharyngitis. Turk J Pediatr 2008; 50:120.
  63. Brook I, Gober AE. Failure to eradicate streptococci and beta-lactamase producing bacteria. Acta Paediatr 2008; 97:193.
  64. Casey JR, Pichichero ME. Symptomatic relapse of group A beta-hemolytic streptococcal tonsillopharyngitis in children. Clin Pediatr (Phila) 2007; 46:307.
  65. Brook I, Gober AE. Recovery of interfering and beta-lactamase-producing bacteria from group A beta-haemolytic streptococci carriers and non-carriers. J Med Microbiol 2006; 55:1741.
  66. Gaffney RJ, Freeman DJ, Walsh MA, Cafferkey MT. Differences in tonsil core bacteriology in adults and children: a prospective study of 262 patients. Respir Med 1991; 85:383.
  67. Lund B, Edlund C, Rynnel-Dagöö B, et al. Ecological effects on the oro- and nasopharyngeal microflora in children after treatment of acute otitis media with cefuroxime axetil or amoxycillin-clavulanate as suspensions. Clin Microbiol Infect 2001; 7:230.
  68. Lafontaine ER, Wall D, Vanlerberg SL, et al. Moraxella catarrhalis coaggregates with Streptococcus pyogenes and modulates interactions of S. pyogenes with human epithelial cells. Infect Immun 2004; 72:6689.
  69. Gaffney RJ, Cafferkey MT. Bacteriology of normal and diseased tonsils assessed by fine-needle aspiration: Haemophilus influenzae and the pathogenesis of recurrent acute tonsillitis. Clin Otolaryngol Allied Sci 1998; 23:181.
  70. Brook I, Yocum P, Foote PA Jr. Changes in the core tonsillar bacteriology of recurrent tonsillitis: 1977-1993. Clin Infect Dis 1995; 21:171.
  71. Brook I. Overcoming penicillin failures in the treatment of Group A streptococcal pharyngo-tonsillitis. Int J Pediatr Otorhinolaryngol 2007; 71:1501.
  72. Falck G, Grahn-Håkansson E, Holm SE, et al. Tolerance and efficacy of interfering alpha-streptococci in recurrence of streptococcal pharyngotonsillitis: a placebo-controlled study. Acta Otolaryngol 1999; 119:944.
  73. Roos K, Holm SE, Grahn-Håkansson E, Lagergren L. Recolonization with selected alpha-streptococci for prophylaxis of recurrent streptococcal pharyngotonsillitis--a randomized placebo-controlled multicentre study. Scand J Infect Dis 1996; 28:459.
  74. Roos K, Holm SE, Grahn E, Lind L. Alpha-streptococci as supplementary treatment of recurrent streptococcal tonsillitis: a randomized placebo-controlled study. Scand J Infect Dis 1993; 25:31.
  75. Wozniak A, Scioscia N, Geoffroy E, et al. Importance of adhesins in the recurrence of pharyngeal infections caused by Streptococcus pyogenes. J Med Microbiol 2017; 66:517.
  76. Ogawa T, Terao Y, Okuni H, et al. Biofilm formation or internalization into epithelial cells enable Streptococcus pyogenes to evade antibiotic eradication in patients with pharyngitis. Microb Pathog 2011; 51:58.
  77. Podbielski A, Beckert S, Schattke R, et al. Epidemiology and virulence gene expression of intracellular group A streptococci in tonsils of recurrently infected adults. Int J Med Microbiol 2003; 293:179.
  78. el-Daher NT, Hijazi SS, Rawashdeh NM, et al. Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V. Pediatr Infect Dis J 1991; 10:126.
  79. CATANZARO FJ, STETSON CA, MORRIS AJ, et al. The role of the streptococcus in the pathogenesis of rheumatic fever. Am J Med 1954; 17:749.
  80. BROCK LL, SIEGEL AC. Studies on the prevention of rheumatic fever; the effect of time of initiation of treatment of streptococcal infections on the immune response of the host. J Clin Invest 1953; 32:630.
  81. Davies HD, McGeer A, Schwartz B, et al. Invasive group A streptococcal infections in Ontario, Canada. Ontario Group A Streptococcal Study Group. N Engl J Med 1996; 335:547.
  82. KRAUSE RM, RAMMELKAMP CH Jr, DENNY FW Jr, WANNAMAKER LW. Studies of the carrier state following infection with group A streptococci. 1. Effect of climate. J Clin Invest 1962; 41:568.
  83. Kemble SK, Westbrook A, Lynfield R, et al. Foodborne outbreak of group a streptococcus pharyngitis associated with a high school dance team banquet--Minnesota, 2012. Clin Infect Dis 2013; 57:648.
  84. Levy M, Johnson CG, Kraa E. Tonsillopharyngitis caused by foodborne group A streptococcus: a prison-based outbreak. Clin Infect Dis 2003; 36:175.
  85. Katzenell U, Shemer J, Bar-Dayan Y. Streptococcal contamination of food: an unusual cause of epidemic pharyngitis. Epidemiol Infect 2001; 127:179.
  86. Decker MD, Lavely GB, Hutcheson RH Jr, Schaffner W. Food-borne streptococcal pharyngitis in a hospital pediatrics clinic. JAMA 1985; 253:679.
  87. Todd EC, Greig JD, Michaels BS, et al. Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 11. Use of antiseptics and sanitizers in community settings and issues of hand hygiene compliance in health care and food industries. J Food Prot 2010; 73:2306.
  88. Sarvghad MR, Naderi HR, Naderi-Nassab M, et al. An outbreak of food-borne group A Streptococcus (GAS) tonsillopharyngitis among residents of a dormitory. Scand J Infect Dis 2005; 37:647.
  89. McCormick JB, Hayes P, Feldman R. Epidemic streptococcal sore throat following a community picnic. JAMA 1976; 236:1039.
  90. Kaplan EL. Editorial commentary: The epidemiology of group a streptococci: a need to understand the significance of the fertile fields. Clin Infect Dis 2012; 55:488.
  91. Nordström T, Pandey M, Calcutt A, et al. Enhancing Vaccine Efficacy by Engineering a Complex Synthetic Peptide To Become a Super Immunogen. J Immunol 2017; 199:2794.
  92. Burlet E, HogenEsch H, Dunham A, Morefield G. Evaluation of the Potency, Neutralizing Antibody Response, and Stability of a Recombinant Fusion Protein Vaccine for Streptococcus pyogenes. AAPS J 2017; 19:875.
  93. Williamson DA, Smeesters PR, Steer AC, et al. Comparative M-protein analysis of Streptococcus pyogenes from pharyngitis and skin infections in New Zealand: Implications for vaccine development. BMC Infect Dis 2016; 16:561.
  94. Good MF, Pandey M, Batzloff MR, Tyrrell GJ. Strategic development of the conserved region of the M protein and other candidates as vaccines to prevent infection with group A streptococci. Expert Rev Vaccines 2015; 14:1459.