Management of Strep for Pharmacy Teams Materials

A GUIDE FOR THE MANAGEMENT OF STREPTOCOCCAL PHARYNGITIS FOR PHARMACY TEAMS

L. Austin Fredrickson, MD, FACP

L. Austin Fredrickson, MD, FACP, is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care.

Topic Overview

Streptococcal pharyngitis, commonly referred to as "strep throat," is a prevalent bacterial infection encountered in clinical practice. An estimated 1- 2% of all visits to physician offices and emergency departments are the result of sore throat. It is important to accurately identify Group A β-hemolytic Streptococcus (GAS) as the cause of sore throat, as this is the only common etiology for which patients should receive antibiotic therapy to treat the condition and prevent potential complications. The Infectious Disease Society of America (IDSA) last published guidelines for GAS pharyngitis in 2012. As important members of interprofessional care teams, pharmacists and pharmacy technicians can assist in optimizing the outcomes of patients with GAS pharyngitis through collaboration with the health care team. Patients often visit their local pharmacy to seek recommendations for sore throat relief. In these cases, pharmacists can evaluate and refer patients to their primary care provider when streptococcal pharyngitis seems likely. Pharmacists can also counsel patients and caregivers on prescribed antibiotics and supplemental analgesics and offer strategies to prevent transmission to others. This continuing education presentation aims to provide pharmacists and pharmacy technicians with a comprehensive understanding of the pathophysiology, risk factors, diagnostic approaches, and evidence-based management strategies associated with streptococcal pharyngitis.

Accreditation Statement:

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is

Pharmacist  0669-0000-24-075-H01-P

Pharmacy Technician  0669-0000-24-076-H01-T

Credits: 1.5 contact hour(s) (0.15 CEU(s)) of continuing education credit

Type of Activity: Knowledge

Media: Internet/Home study Fee Information: $5.99

Estimated time to complete activity: 1.5 contact hour(s) (0.15 CEU(s)), including Course Test and course evaluation

Release Date: June 27, 2024 Expiration Date: June 27, 2027

Target Audience: This educational activity is for pharmacists and pharmacy technicians

How to Earn Credit: From June 27, 2024, through June 27, 2027, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “Educational Activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Credit for this course will be uploaded to CPE Monitor®.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe the pathophysiology of and risk factors for streptococcal pharyngitis

Identify the clinical presentation of streptococcal pharyngitis, including common signs and symptoms

Describe the evaluation of a patient with streptococcal pharyngitis

Compare and Contrast treatment strategies for the management of streptococcal pharyngitis

Disclosures

The following individuals were involved in developing this activity: L. Austin Fredrickson, MD, FACP, and Pamela Sardo, PharmD, BS. Pamela Sardo and L. Austin Fredrickson have no conflicts of interest or financial relationships regarding the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

©RxCe.com LLC 2024: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Educational Activity

A Guide for the Management of Streptococcal Pharyngitis for Pharmacy Teams

Introduction

Streptococcal pharyngitis is an infection of the throat caused by Streptococcus pyogenes. This condition is commonly referred to as strep throat and presents with throat soreness. Pharmacists and pharmacy technicians, as members of an interprofessional care team, can assist in optimizing the outcomes of patients with Streptococcal pharyngitis through healthcare team collaboration. This continuing education presentation aims to provide pharmacists and pharmacy technicians with a comprehensive understanding of the pathophysiology, risk factors, diagnostic approaches, and evidence-based management strategies associated with streptococcal pharyngitis. This will enable pharmacists with patient evaluations when patients visit their local pharmacy to seek recommendations for sore throat relief. In these cases, a referral to the patient’s primary care provider may be appropriate if streptococcal pharyngitis seems likely. Pharmacists can also counsel patients and caregivers on prescribed antibiotics and supplemental analgesics and offer strategies to prevent transmission to others.

Etiology and Epidemiology

Streptococcal pharyngitis is commonly called "strep throat" and is identified as a sore throat. It is caused by the Group A β-hemolytic Streptococcus (GAS), a gram-positive bacterium known as streptococcus pyogenes. Streptococcus pyogenes grows in chains and is a host-adapted pathogen.1-4

It produces numerous virulence factors that affect tissues, cells, and various immune response components.4 Examples of its surface-bound virulence factors include the M protein, S protein, and hyaluronic acid capsule.4 The M protein inhibits phagocytosis and enables tissue invasion,

while the hyaluronic capsule protects the bacteria from phagocytosis.5 Secreted virulence factors include deoxyribonucleases, streptokinase, superantigens, and immunoglobulin-degrading enzymes.4

Streptococcal pharyngitis is a prevalent bacterial infection encountered in clinical practice.1 An estimated 1-2% of all visits to physician offices and emergency departments are the result of sore throat.1,2 It is important to accurately identify GAS as the cause of sore throat, as this is the only common etiology for which patients should receive antibiotic therapy to treat the condition and prevent potential complications.1,3 As of this writing, the Infectious Disease Society of America (IDSA) last published guidelines for group A streptococcal (GAS) pharyngitis in 2012.3 The medical literature refers to GAS and GABHS (adding the β-hemolytic emphasis) interchangeably, but this text will utilize GAS in accordance with the IDSA convention.

GAS is the cause of pharyngitis in up to 15% of adults and 35% of children in the United States (US).1 Its prevalence among children peaks between the ages of 7 and 8, but children of any age can become infected.5 This bacterium is transmitted via respiratory secretions, most commonly during late winter and early spring.6 The incubation period is between 24 and 72 hours, and patients are able to transmit the infection to others during this time.1,5 Risk factors for developing GAS pharyngitis are detailed in Table 1.6

Table 1. Risk Factors for GAS Pharyngitis6

Clinical Presentation and Diagnosis

The primary goal of assessing patients with a sore throat is to determine if GAS is the cause of pharyngitis.1,3 This is important as a sore throat can result from many underlying issues, including thyroiditis, gastroesophageal reflux, and postnasal drainage.7 Table 2 details findings that suggest non- streptococcal pharyngitis.6 Table 3 details the clinical presentation of GAS pharyngitis, comparing it to signs suggestive of other etiologies.7 Older children tend to present with fever, sore throat, tender anterior cervical adenopathy, and pharyngeal and tonsillar exudate, while younger children have rhinitis, fever, and irritability.5

Table 2. Forms of Non-Streptococcal Pharyngitis6

Table 3. Clinical Presentation of GASBH Pharyngitis8

Scoring Systems

Clinicians should only prescribe antibiotic therapy when the presence of GAS is likely to preserve the efficacy of antibiotics and prevent antibiotic resistance.6 In most cases, adult patients will instead have viral pharyngitis.6 This differs from the prevalence of GAS in children, which is higher at an estimated rate of 35%.6 To properly diagnose GAS pharyngitis, clinicians should first complete a physical examination and obtain a thorough patient history.1 Providers can then use the Centor Criteria to determine the likelihood of a GAS infection. It is important to note that no single symptom can be used to diagnose GAS pharyngitis definitively.1 Thus, an algorithm should be utilized to integrate key information and make an informed decision.

The Centor scoring system provides an easy and accurate method for stratifying patients and is presented in Table 4.6 The four Centor Criteria include a history of fever, absence of cough, tender anterior cervical lymphadenopathy, and tonsillar exudate or swelling. Each criterion receives

one point.6 Adults with two or three Centor points have a medium risk of GAS pharyngitis and should have a test performed.6 The results can be used to determine the ultimate treatment strategy.6 It is reasonable for an adult patient with four Centor points to either empirically treat or provide a rapid test.6

Table 4. The Centor Criteria and the Probability of Streptococcal Pharyngitis for Adults6

Centor criteria are not as specific for pediatric patients.6 Any child with conjunctivitis, runny nose, cough, hoarseness, or nonexudative oral lesions should be tested for GAS pharyngitis.6

Diagnostic Testing

Diagnostic testing is generally not recommended in children under three and in patients with symptoms suggestive of a virus, such as cough, rhinorrhea, or hoarseness.9 Clinical judgment is key, however; for example, a clinician could test a child under three years of age if their siblings have GAS.5 Testing options include the rapid antigen detection test (RADT) and performing a throat culture. The RADT is a convenient test with high specificity (95%) and a sensitivity of 80%.6 It is important that whoever performs the test does so accurately to avoid affecting test results.6 This test is performed by rubbing the tonsils and pharynx and touching areas with ulcers or exudates.6 Benefits include receiving results within minutes and allowing clinicians to provide a treatment strategy with the patient present.6 If the test is negative, a throat culture should be done to confirm the result.5 Patients

may gag or cough, so care needs to be taken to be efficient and get a suitable sample before patients, especially pediatric patients, react to the testing. By being quick and effective, patients will only temporarily feel discomfort from the testing.

Throat cultures have higher sensitivity levels (85-90%) than RADTs.6 However, false positives are possible and occur in patients who are carriers of GAS but not actively infected.6 The test also has low specificity (50-70%), especially in patients without serologic evidence of infection.6 If a patient has zero or one Centor criteria, a positive test is more likely to be a false positive.6 Finally, this test requires 24-48 hours to receive the results.6 Due to these considerations, throat cultures are not recommended for routine evaluation of adult patients with sore throats.6

Management of Streptococcal Pharyngitis

The goal of treating streptococcal pharyngitis is to reduce symptoms while eradicating the infection.6 Additionally, clinicians must minimize adverse drug reactions, prevent complications such as acute rheumatic fever, and help patients prevent transmitting GAS to close contacts.7 Nonpharmacologic treatment options include using saline, honey, and humidification.6

Pharmacologic Treatment

All patients presenting with sore throats should be offered analgesic therapy, regardless of whether or not GAS is present.6 Analgesic therapy can include the use of either acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs).6 The choice of analgesic will depend on patient preference as well as the presence of comorbidities, contraindications, and potential interactions with other drug therapies.6 Importantly, aspirin should not be given to children to prevent the development of Reye’s syndrome.6 Other simple remedies may include cough lozenges, Chloraseptic sprays, warm salt water gargles, and cold drinks or ‘slushies.’

Patients with GAS should receive antibiotics within nine days of symptom onset.5 Penicillin is the antibiotic of choice for the treatment of streptococcal pharyngitis.3 Penicillin is a beta-lactam antibiotic that works by inhibiting peptidoglycan synthesis.10 It consists of a thiazolidine ring connected to a beta-lactam ring attached to a side chain. It provides activity against sensitive strains of gram-positive cocci bacteria, including streptococcus A.10 Its use in treating GAS pharyngitis is beneficial, given its efficacy against this bacterial strain, its low cost, and its low risk of side effects.6 The most common side effects of penicillin include nausea and rash.11 However, the care team should determine the treatment regimen with the patient and consider whether the patient has penicillin and/or other allergies to antibiotics, the potential for drug-drug interactions, and the potential for medication nonadherence, including insurance coverage, cost, and even national and local drug shortages.11,13 In these situations, alternative agents described below and listed in Table 5 may be utilized.

Oral, first-generation cephalosporins such as cephalexin and cefadroxil can be used for patients with a mild penicillin allergy, and erythromycin, clarithromycin, and clindamycin can be used for patients with severe penicillin allergies.6 These antibiotics must be given for at least seven to ten days for maximum efficacy.6 Table 5 details antibiotics and corresponding dosing for the treatment of GAS.7

A 2021 Cochrane review assessed the efficacy of different antibiotics to evaluate their effectiveness in treating streptococcal pharyngitis by comparing their ability to (a) reduce symptoms like pain and fever, (b) decrease the length of the illness, (c) prevent clinical relapses, and (d) avert complications such as suppurative complications, acute rheumatic fever, and post- streptococcal glomerulonephritis.13 Additionally, the study examined the comparative incidence of side effects and assessed the overall risk-benefit ratio of using antibiotics for this condition.11 The study involved 19 trials with 5,839 participants, comparing different classes of antibiotics for treating acute GAS tonsillopharyngitis in a range of ages from one month to 80 years, mainly in outpatient settings.11 The reliability of these trials was questioned due to

poor reporting on randomization and blinding, alongside methodological heterogeneity. These findings are summarized below.11

Cephalosporins vs. Penicillin: The study found uncertain results regarding whether cephalosporins are more effective than penicillin in resolving symptoms or reducing clinical relapses. Evidence showed no significant difference in adverse events between the two drugs.

Macrolides vs. Penicillin: Uncertainties were noted when comparing macrolides to penicillin in symptom resolution and relapse rates. However, children treated with macrolides experienced more adverse events than those treated with penicillin, although the subgroup analysis between children and adults showed no significant differences.

Azithromycin vs. Amoxicillin: In a single study of children, it was unclear whether a single dose of azithromycin was more effective than a 10-day course of amoxicillin in resolving symptoms or reducing relapses.5 Azithromycin was associated with more adverse events.

Carbacephem vs. Penicillin: Evidence suggested that carbacephem might be more effective than penicillin in improving symptom resolution in adults and children.

Overall, the study did not address long-term complications, leaving it unclear if any antibiotic class was superior in preventing serious but rare complications.11 The quality of evidence across all comparisons was generally low, reflecting significant uncertainties about the efficacy and safety of these antibiotics for streptococcal pharyngitis.11

Table 5. Antibiotic Therapies for GAS7

Antibiotics may also be utilized in chronic carriers. Table 6 presents these agents and associated doses.7 In many cases, antibiotics are not recommended for these patients, but there are some situations in which they may be warranted. These include the following:8

During a community outbreak of acute rheumatic fever, acute post- streptococcal glomerulonephritis, or invasive group A streptococcal infection

During an outbreak of group A streptococcal pharyngitis in a closed or partially closed community

When the patient has a family or personal history of acute rheumatic fever

When the patient or family has excessive anxiety about group A streptococcal infections

When tonsillectomy is being considered only because the patient is a chronic carrier

Table 6. Antibiotic Dosing to Eradicate GAS Pharyngitis in Chronic Carriers7

Monitoring and Follow-Up

In general, patients should see symptoms begin to resolve within 3-5 days.7 If the following warning symptoms occur, patients should be instructed to seek additional care: the child starts shaking or has neck swelling, trouble swallowing, or any symptoms that remain beyond five days without improving.7 Separately, if patients have trouble swallowing secretions, breathing comfortably at rest, altered mental status, syncope, or high fevers refractory to antipyretic medications.

Complications of Streptococcal Pharyngitis

Streptococcal pharyngitis is associated with numerous suppurative and nonsuppurative complications. These are presented in Table 7.8

Table 7. Complications of GAS8

Acute rheumatic fever (ARF) is an autoimmune response to streptococcus pharyngitis.14 This condition results from either untreated or improperly treated GAS pharyngitis.14 ARF may result in heart valve damage that can persist or worsen over the course of years.13 It predominantly affects children aged 5-14, with initial episodes becoming less common in older adolescents and young adults.13

Acute rheumatic fever typically manifests after a period of approximately three weeks following a group A streptococcal infection, though this period can extend up to six months.13 Many patients will recall having a sore throat, but the preceding infection is often subclinical and only detectable via streptococcal antibody testing.13 ARF's most common clinical features are polyarthritis, present in 60-75% of cases, and carditis, which affects 50-75% of patients.14 Other manifestations, including erythema marginatum and subcutaneous nodules, occur in less than 5% of cases.13 The Jones criteria, last revised in 2015, are useful in diagnosing and providing criteria specific to low, moderate, and high-risk populations.5 Diagnostic criteria vary based on whether the patient is from a low-risk or moderate-/high-risk population.5 Moderate- and high-risk populations include regions where ARF is endemic, such as Africa, Asia-Pacific, and the indigenous populations of Australia.5 The United States, Canada, and Europe are considered low-risk areas. All patients, except those with chorea, require evidence of a previous GAS infection:5

Initial Diagnosis: Requires either 2 major criteria or 1 major and 2 minor criteria

Recurrent Diagnosis: Requires either 2 major criteria, 1 major and 2 minor criteria, or 3 minor criteria.

Criteria for Diagnosis:

Low-Risk Population:

Major Criteria:

Carditis (clinical or subclinical)

Polyarthritis

Chorea

Subcutaneous nodules

Erythema marginatum

Minor Criteria:

Polyarthralgia

- Fever (≥101.3°F [38.5°C])

Elevated ESR (≥60 mm/hr) and/or CRP (≥3 mg/dL [30 mg/L])

Prolonged PR interval (without carditis)

Moderate-/High-Risk Population:

Major Criteria:

Carditis (clinical or subclinical)

Arthritis (polyarthritis, monoarthritis, or polyarthralgia)

Chorea

Subcutaneous nodules

Erythema marginatum

Minor Criteria:

Monoarthralgia

- Fever (≥100.4°F [38°C])

Elevated ESR (≥30 mm/hr) and/or CRP (≥3 mg/dL [30 mg/L])

Heart involvement in ARF leads to rheumatic heart disease (RHD) in up to 75% of patients, affecting the endocardium, pericardium, or myocardium.14 Valvular damage is a hallmark of rheumatic carditis, with the mitral valve almost always involved, often alongside the aortic valve. Isolated aortic valve involvement is rare.13 Early valvular damage causes regurgitation, progressing

to leaflet thickening, scarring, calcification, and stenosis due to recurrent episodes.13

Joint involvement typically presents as polyarthritis, characterized by hot, swollen, red, and tender joints. It affects multiple joints in a migratory pattern.13 The large joints, such as knees, ankles, hips, and elbows, are most involved, and the pain is severe until anti-inflammatory treatment begins.13 Less severe joint involvement, including arthralgia without objective inflammation and aseptic monoarthritis, is also recognized. These issues respond well to salicylates and NSAIDs, and persistent joint symptoms beyond 1-2 days of treatment likely indicate another cause.13

In treating ARF, the goal is to eradicate the infection using a standard antibiotic regimen and then start secondary prophylaxis to prevent new infections.5 Prophylaxis for acute rheumatic fever may include either benzathine penicillin G, given intramuscularly as a single dose every four weeks, or oral penicillin V, given at 250 mg twice a day.5 Patients with penicillin allergies can use a macrolide.5 The duration of prophylaxis depends on the patient’s condition.5 Those with rheumatic fever without carditis should receive prophylaxis for five years following their last ARF episode or until age 21, whichever is longer.5 If they have rheumatic fever with carditis but no valvular disease, the duration is 10 years from their last episode or until age 21, whichever is longer.5 Finally, those with rheumatic fever, carditis, and persistent valvular disease should receive prophylaxis for 10 years following their last episode or until age 40, whichever is longer.5 Lifelong prophylaxis can also be considered if they may be continually exposed to GAS.5

Patients may also develop post-streptococcal reactive arthritis following GAS infection.5 This can occur without the clinical and laboratory findings needed to diagnose ARF using the Jones criteria.5 Patients who develop this condition should be monitored for 1-2 years to see if carditis develops.5 They should also receive secondary prophylaxis during this time.5

The Role of the Pharmacy Technician on the Interprofessional Care Team

Pharmacy technicians practicing in community retail or independent pharmacy settings can assist the care team in identifying patients seeking relief for sore throat, recommending from the options listed above. Technicians can speak with pharmacists to ensure such patients are appropriately referred to their primary care provider to receive proper evaluation and testing for streptococcal pharyngitis when warranted. Being familiar with the dosing and labeling instructions is paramount, especially when caregivers of children have to dispense liquid formulations with their measurements. Additionally, pharmacy technicians can inform pharmacists when patients require counseling for their antibiotic therapies or who may struggle with medication adherence.

Additional Resources

IDSA Guidelines:

https://www.idsociety.org/practice-guideline/streptococcal-pharyngitis/

Summary

Streptococcal pharyngitis, commonly known as "strep throat," is a significant bacterial infection encountered frequently in clinical practice, accounting for 1-2% of all physician office and emergency department visits. It is crucial to identify GAS as the cause since it is the primary sore throat etiology that warrants antibiotic treatment to alleviate symptoms and prevent complications. The last guidelines for managing GAS pharyngitis by the IDSA were published in 2012. Pharmacists and pharmacy technicians are essential in optimizing patient outcomes through interprofessional collaboration, patient education on antibiotics and analgesics, and strategies to prevent transmission.

Course Test

During which seasons is Group A β-hemolytic Streptococcus (GAS) pharyngitis most commonly transmitted?

Summer and fall

Summer and winter

Winter and spring

Spring and summer

A 7-year-old male presents to the pharmacy with a sore throat. Which of the following conditions is most likely to respond to antibiotic therapy?

Influenza A virus

A β-hemolytic Streptococcus

Gastroesophageal reflux

Seasonal allergies

Which of the following combination of symptoms is most suggestive of GAS pharyngitis?

Conjunctivitis, coryza, cough

Sore throat, painful swallowing, fever

Scarlatiniform rash, pseudomembrane on examination

New sexual partner, fever, rash, myalgias

What is the best clinical approach for an adult patient with zero Centor points?

No test, no antibiotic

Rapid test

Empirical antibiotic treatment

Further diagnostic testing

Which of the following is NOT one of the four Centor Criteria used to assess the likelihood of GAS pharyngitis?

History of fever

Absence of cough

Sore throat

Tender anterior cervical lymphadenopathy

Which diagnostic test for GAS pharyngitis is known for its high specificity but lower sensitivity than the other test?

Rapid antigen detection test (RADT)

Throat culture

Complete blood count

Chest X-ray

Which of the choices below best describes the primary goal(s) of treating streptococcal pharyngitis?

To alleviate symptoms and eradicate the infection

To eliminate all forms of bacteria in the throat

To prevent viral shedding

To prevent postinfectious irritable bowel syndrome

Which antibiotic is the drug of choice for treating streptococcal pharyngitis?

Cephalexin

Penicillin

Clindamycin

Azithromycin

For patients with a severe penicillin allergy, which antibiotic is recommended for treating streptococcal pharyngitis?

Cephalexin, carbacephem

Erythromycin, clarithromycin, clindamycin

Amoxicillin, ampicillin

Cefadroxil, cephalexin

The school nurse evaluated an 8-year-old female in February for a sore throat that had been present for several weeks and a constellation of symptoms, including ongoing fevers, joint aches, subcutaneous nodules, chorea, and a new rash. The workup revealed elevated ESR and CRP. What is the likely etiology of her condition?

HIV infection leading to Reyes syndrome

GAS infection leading to rheumatic fever

Rheumatoid arthritis

Viral pharyngitis

References

Mustafa Z, Ghaffari M. Diagnostic Methods, Clinical Guidelines, and Antibiotic Treatment for Group A Streptococcal Pharyngitis: A Narrative Review. Front Cell Infect Microbiol. 2020;10:563627. Published 2020 Oct 15. doi:10.3389/fcimb.2020.563627

Prevention CfDCa (2016. a). National Ambulatory Medical Care Survey:2016 National Summary Tables. https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_w eb_tables.pdf. Accessed June 26, 2024.

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 [published correction appears in Clin Infect Dis. 2014 May;58(10):1496. Dosage error in article text]. Clin Infect Dis. 2012;55(10):1279-1282. doi:10.1093/cid/cis847

Brouwer S, Rivera-Hernandez T, Curren BF, et al. Pathogenesis, epidemiology and control of Group A Streptococcus infection [published correction appears in Nat Rev Microbiol. 2023 Sep;21(9):619]. Nat Rev Microbiol. 2023;21(7):431-447. doi:10.1038/s41579-023-00865-7

Group A Streptococcus Infections

Choby B. Diagnosis and Treatment of Streptococcal Pharyngitis. Am Fam Physician. 2009;79(5):383-390.

Amdur RL, Linder JA. Upper Respiratory Symptoms, Including Earache, Sinus Symptoms, and Sore Throat. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. eds. Harrison's Principles of Internal Medicine, 21e. McGraw-Hill Education; 2022.

Respiratory Tract Infections, Upper. In: Wells BG, DiPiro JT, Schwinghammer TL, DiPiro CV. eds. Pharmacotherapy Quick Guide. McGraw-Hill Education; 2017.

Randel A. ISDA Updates Guideline for Managing Group A Streptococcal Pharyngitis. Am Fam Phyisician. 2013; 88(5): 338-40.

Penicillins, Cephalosporins, and Other β-Lactam Antibiotics. In: Hilal- Dandan R, Brunton LL. eds. Goodman and Gilman's Manual of Pharmacology and Therapeutics, 2e. McGraw-Hill Education; 2016.

Peniciilin PPI. Baxter Healthcare Corporation. 2016. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/050638s0 19lbl.pdf. Accessed June 26, 2024.

Shukar S, Zahoor F, Hayat K, et al. Drug Shortage: Causes, Impact, and Mitigation Strategies. Front Pharmacol. 2021;12:693426. Published 2021 Jul 9. doi:10.3389/fphar.2021.693426

van Driel ML, De Sutter AI, Thorning S, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane

Database Syst Rev. 2021;3(3):CD004406. Published 2021 Mar 17. doi:10.1002/14651858.CD004406.pub5

Kado J, Carapetis J. Acute Rheumatic Fever. In: Loscalzo J, Fauci A, Kasper D, Hauser S, Longo D, Jameson J. eds. Harrison's Principles of Internal Medicine, 21e. McGraw-Hill Education; 2022.

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The information provided in this course is general in nature and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

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