A GUIDE FOR THE MANAGEMENT OF STREPTOCOCCAL PHARYNGITIS FOR PHARMACY TEAMS
Faculty:
L. Austin Fredrickson, MD, FACP
L. Austin Fredrickson 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.
Liz Fredrickson, PharmD, BCPS
Liz Fredrickson, PharmD, BCPS, is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy, where she is course director of the Parenteral Products and Basic Pharmaceutics Lab courses.
Kristina (Tia) Neu, RN
Kristina (Tia) Neu is a licensed Registered Nurse and author currently developing in-service training for healthcare professionals. She is a National Board-Certified Health & Wellness and Lifestyle Medicine Coach. Her work experience includes several areas of the healthcare profession, such as psychiatric nursing, medical nursing, motivational health coaching, chronic case management, dental hygiene, cardiac technician, surgical technician, and clinical director of a Clinically Integrated Network (CIN).
Pamela Sardo, PharmD, BS
Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.
Abstract
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 due to a 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 help optimize outcomes for patients with GAS pharyngitis by collaborating with the health care team. Patients often visit their local pharmacy to seek recommendations for sore throat relief. In these cases, pharmacists can evaluate patients and refer them to their primary care provider when streptococcal pharyngitis is 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 Statements
In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation CouncilTM for Continuing Medical Education (ACCME®), the Accreditation Council for Pharmacy Education (ACPE®), and the American Nurses Credentialing Center (ANCC®), to provide continuing education for the healthcare team.
Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:
Pharmacists: JA4008424-0000-26-085-H01-P
Pharmacy Technicians: JA4008424-0000-26-085-H01-T
Credits: 2 contact hour(s) (0.2 CEU(s)) of continuing education credit.
Credit Types:
Pharmacy - 2 Credits
Type of Activity: Knowledge
Media: Computer-Based Training (i.e., online courses)
Estimated time to complete activity: 2 contact hour(s) (0.2 CEU(s)), including Course Test and course evaluation
Release Date: June 15, 2026 Expiration Date: June 27, 2027
Target Audience: This educational activity is for Pharmacists and Pharmacy Technicians
How to Earn Credit: From June 15, 2026, through June 27, 2027, participants must:
Read the “learning objectives” and “author and planning team disclosures;”
Take the “Educational Activity Pre-Test;”
Study the section entitled “Educational Activity;” and
Complete the Educational Activity Post-Test and Activity Evaluation. The Educational Activity Post-Test will be graded automatically. Following successful completion of the Educational Activity Post-Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)
CE Credits: Credits for this course will be uploaded to CPE Monitor® for pharmacists and pharmacy technicians.
Statement of Need
Streptococcal pharyngitis, commonly referred to as "strep throat," is a prevalent bacterial infection encountered in clinical practice. As important members of interprofessional care teams, pharmacists and pharmacy technicians can help optimize outcomes for patients with GAS pharyngitis by collaborating with the health care team. This requires an understanding of the pathophysiology, risk factors, diagnostic approaches, and evidence-based management strategies associated with streptococcal pharyngitis.
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 planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Kristina (Tia) Neu, RN; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to 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 2026: 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 Pre-Test
Which of the following combinations 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
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 persisted 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
Rheumatoid arthritis
Viral pharyngitis
GAS infection leading to rheumatic fever
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 help optimize outcomes for patients with Streptococcal pharyngitis through 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 to provide patient evaluations when patients visit their local pharmacy for sore throat relief recommendations. 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, commonly called "strep throat," is 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 components of the immune response.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 a 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
| Winter and spring seasons | Healthcare workers |
|---|---|
| Teachers | Childcare workers |
| Parents of young children | Patients exposed to individuals with strep throat |
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
| Clinical Findings or Behavioral Factors | Suspected Diagnosis |
|---|---|
| Scarlatiniform rash | Group A β-hemolytic streptococci or Arcanobacterium haemolyticum |
| Cough and otitis media | Haemophilus influenzae |
| Sex between men with associated urogenital symptoms, fellatio between a woman and a man who has current urogenital symptoms, and a persistent sore throat unresponsive to penicillin | Neisseria gonorrhoeae |
| Travel to endemic areas, pseudomembrane on examination | Corynebacterium diphtheriae |
| Persistent sore throat with bronchopulmonary symptoms | Mycoplasma pneumoniae |
| Marked adenopathy (especially that involving posterior cervical or auricular nodes), splenomegaly, palatine petechiae, gelatinous uvula | Acute infectious mononucleosis |
| New sexual partner in the previous month; fever, rash, myalgias, headache | Acute HIV infection |
Table 3
Clinical Presentation of GASBH Pharyngitis8
General
|
|---|
Signs and symptoms of GAS pharyngitis
|
Signs that suggest a viral origin for pharyngitis
|
Scoring Systems
Clinicians should prescribe antibiotic therapy only when GAS is likely to be present, thereby preserving antibiotic efficacy and preventing 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 definitively diagnose GAS pharyngitis.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
| NO. OF CRITERIA METb | POST EVALUATION PROBABILITY (%) | RECOMMENDATION |
|---|---|---|
| 0 | 2 | No test, no antibiotic |
| 1 | 3 | No test, no antibiotic |
| 2 | 8 | Rapid test |
| 3 | 19 | Rapid test |
| 4 | 41 | Empirical antibiotic treatment or rapid test |
The Centor criteria are less 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 3 and in patients with symptoms suggestive of a viral infection, 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, the testing will only cause patients to feel temporary discomfort.
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 analgesics 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 used.
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 inconclusive evidence on whether cephalosporins are more effective than penicillin at 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
| Antibiotic | Brand Name | Dose | Duration |
|---|---|---|---|
| Penicillin V | Pen-V® | Children </27 kg: 250 mg twice daily or three times daily orally Children >27 kg: 500 mg twice daily or three times daily orally Adult: 250 mg four times daily or 500 mg twice daily orally | 10 days |
| Penicillin G benzathine | Bicillin L-A® | </ 27 kg: 0.6 million units > 27 kg: 1.2 million units intramuscularly | One dose |
| Amoxicillin | Amoxil® | 50 mg/kg once daily (maximum 1000 mg) | 10 days |
| Cephalexin | Keflex® | 20 mg/kg/dose orally twice daily (maximum 500 mg/dose) | 10 days |
| Cefadroxil | Duricef® | 30 mg/kg orally once daily (maximum 1 g) | 10 days |
| Clindamycin | Cleocin® | 7 mg/kg/dose orally three times a day (maximum 300 mg/dose) | 10 days |
| Azithromycin | Zithromax® | 12 mg/kg orally once daily (maximum 500 mg) for one day, then 6 mg/kg orally once daily (maximum 250 mg) for four days | 5 days |
| Clarithromycin | Biaxin® | 15 mg/kg orally per day, divided into two doses (maximum 250 mg twice daily) | 10 days |
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
| Antibiotic | Brand Name | Dose |
|---|---|---|
| Clindamycin | Cleocin® | 20–30 mg/kg/day orally in three divided doses (maximum 300 mg/dose) |
| Amoxicillin-clavulanate | Augmentin® | 40 mg/kg/day orally in three divided doses (maximum 2000 mg/day of amoxicillin) |
| Penicillin V and rifampin | Pen-V®, Rifadin® | Penicillin V: 50 mg/kg/day orally in four doses for 10 days (maximum 2000 mg/day); and rifampin: 20 mg/kg/day orally in one dose for the last 4 days of treatment (maximum 600 mg/day) |
| Penicillin G benzathine and rifampin | Bicillin L-A®, Rifadin® | Penicillin G benzathine: < 27 kg—0.6 million units; 27 kg or greater—1.2 million units intramuscularly; and rifampin: 20 mg/kg/day orally in two doses during last 4 days of treatment with penicillin (maximum 600 mg/day) |
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
| Suppurative Complications | Nonsuppurative Complications |
|---|---|
| Bacteremia | Rheumatic fever |
| Cervical lymphadenitis | Poststreptococcal glomerulonephritis |
| Endocarditis | Poststreptococcal arthritis |
| Mastoiditis | |
| Meningitis | |
| Otitis media | |
| Peritonsillar/retropharyngeal abscess | |
| Pneumonia |
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 approximately three weeks after 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 with a standard antibiotic regimen and then initiate secondary prophylaxis to prevent recurrent 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 a sore throat and recommending one of the options listed above. Technicians can speak with pharmacists to ensure that such patients are appropriately referred to their primary care provider for proper evaluation and testing for streptococcal pharyngitis when warranted. Being familiar with dosing and labeling instructions is paramount, especially when caregivers of children have to dispense liquid formulations using the specified measurements. Additionally, pharmacy technicians can inform pharmacists when patients require counseling for their antibiotic therapies or who may struggle with medication adherence.
Additional Resource 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, as it is the primary etiology of sore throat that warrants antibiotic treatment to alleviate symptoms and prevent complications. The last IDSA guidelines for managing GAS pharyngitis 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.
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. Accessed June 15, 2026. https://archive.cdc.gov/#/details?url=https://www.cdc.gov/nchs/data/ahcd/namcs_summary/2016_namcs_web_tables.pdf
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. Accessed June 15, 2026. https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/050638s019lbl.pdf
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.
DISCLAIMER
The information provided in this course is general in nature, and it is designed solely 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.
Healthcare professionals must consult their employer, healthcare facility, hospital, or other organization for guidelines, protocols, and procedures to follow. The information provided in this course does not replace those guidelines, protocols, and procedures, but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.
Participants are advised and acknowledge that information related to medications, their administration, dosing, contraindications, adverse reactions, interactions, warnings, precautions, or accepted uses is constantly changing. Any person taking this course understands that such a person must make an independent review of medication information before any patient assessment, diagnosis, treatment and/or health management. Any discussion of off-label use of any medication, device, or procedure is informational only, and such uses are not endorsed hereby.
Nothing contained in this course represents the opinions, views, judgments, or conclusions of RxCe.com LLC. RxCe.com LLC is not liable or responsible to any person for any inaccuracy, error, or omission with respect to this course or course material.
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