If the practitioner has reason to believe that the patient is a recently established carrier just having finished a course of antibiotic for acute GAS infection, asymptomatic or with an apparent viral URI, and culture-positive for GAS , giving one additional course of an appropriate antibiotic not penicillin V alone might be reasonable in an attempt to eradicate the pathogen and buy time to reduce contagiousness. J Infect Dis ; J Pediatr ; N Engl J Med ; 12 Arch Pediatr Adolesc Med ; Arch Otolaryngol Head Neck Surg ; Kaplan EL, Johnson DR: Unexplained reduced microbiological efficacy of intramuscular benzathine penicillin G and of oral penicillin V in eradication of Group A streptococci from children with acute pharyngitis.
Pediatrics ; 5 Pediatrics ;38 2 Am J Dis Child ; Hoffman S: The throat carrier rate of group A and other beta-hemolytic streptococci among patients in general practice. Am J Public Health ; Bacteriologic observations, from October through May Dis Chest ; Ann Intern Med ; Cornfeld D, Hubbard JP: A four-year study of the occurrence of beta-hemolytic streptococci in 64 school children.
N Engl J Med ; Am J Epidemiol ; Quinn RW: Hemolytic streptococci in Nashville school children. South Med J ;73 3 The epidemiology of the acquisition of group A streptococcal and of associated illness. Infectivity of streptococci isolated during acute pharyngitis and during the carrier state.
J Clin Invest ;41 3 Kuttner AG, Krumwiede E: Observations on the effect of streptococcal upper respiratory infections on rheumatic children: A three-year study. J Clin Invest ; In this study of 4 major outbreaks, it was determined that the source of GAS was not from known carriers in the institution but rather from serotypes recently introduced to the population. This discovery led investigators to conclude that although infection from carriers can occur, it is substantially less likely than transmission from a child with active infection.
Also, in a study of military recruits, Wannamaker [ 52 ] observed the risk of transmission from military recruits following new acquisition of GAS in the pharynx. Those recruits who carried GAS for more than 2 weeks were much less likely to transmit the organisms to others. Most importantly, children who are carriers are asymptomatic with regard to respiratory symptoms cough or coryza for the majority of time that they are carriers, which dramatically reduces the likelihood of spread of GAS to the environment.
When a carrier does develop respiratory symptoms secondary to a community-acquired virus, transmission is more likely. The role of carriers in invasive disease is not entirely clear. Although GAS may be found in the pharynx of patients with invasive infection at the time of presentation, it is usually not possible to determine whether the patient was a carrier before infection or was more recently colonized or infected.
However, a common model for respiratory pathogens that cause systemic disease is that if invasive disease is going to occur, it does so within days of acquisition [ 53 ]. GAS carriage is commonly found among close contacts of patients with invasive infections. In a case-control study of children with invasive GAS disease, 1 invasive disease was associated with the presence of other children in the home and 2 in another outbreak setting there was an increase in carriage rates of the invasive GAS strain among school-aged children in the community [ 55 , 56 ].
It is most likely that the carriers served as a reservoir of infection for the patient with invasive disease [ 54 , 56 ]. Perhaps the most significant impact of the carrier state is the confusion it may cause in the evaluation of the patient with symptoms of acute pharyngitis. This confusion arises when the carrier acquires a respiratory virus and presents with sore throat.
An important strategy to minimize this issue is for the practitioner to avoid testing children with prominent nasal symptoms and cough for GAS infection. However, some community-acquired viruses target the pharynx. When the clinician performs a rapid antigen detection test or throat culture, it will be positive because the patient is a carrier and yet a virus is the actual cause of the pharyngitis. The positive test will be interpreted as an acute streptococcal infection, and an antibiotic will be prescribed unnecessarily.
In the clinical setting, there is no practical way to differentiate the carrier from the person with acute infection. This unintended overuse of antimicrobials may have a significant public health impact because it may promote the development of antibiotic resistance, result in adverse events, and add to healthcare costs. Two important questions arise when a GAS carrier has been identified.
Six trials of treatment of the carrier state have been reported in the medical literature Table 2 [ 20 , 60—64 ]. In reviewing these trials, it is important to consider how the carrier state is defined and under what circumstances the study was done. It is important to note that both of these studies were performed over 10 years ago, and recent investigations have shown a rising rate of resistance of GAS to the macrolides and clindamycin.
Although several antimicrobial regimens are variably effective in eradicating GAS carriage, the question remains as to the benefit of treatment to the patient. If there is no risk of nonsuppurative sequelae and the risk of transmission to others is low, it would appear that there may be little to gain by treating carriers. Published guidelines, based on expert opinion, generally recommend against identifying and treating carriers except for the following special situations: 1 a local outbreak of acute rheumatic fever, invasive GAS disease, or poststreptococcal glomerulonephritis; 2 an outbreak of GAS pharyngitis in a closed or semiclosed community; 3 family or personal history of acute rheumatic fever; 4 multiple episodes of GAS pharyngitis occurring in a family for many weeks despite appropriate treatment; and 5 when tonsillectomy is being considered only because of GAS carriage [ 9 , 65 ].
One important reason to consider eradication of carriage is to avoid confusion when the patient presents with subsequent episodes of symptomatic pharyngitis.
This situation may be particularly important in the patient who presents with apparent, closely spaced, recurrent episodes of GAS pharyngitis early in the respiratory season. If the etiology of the carrier's symptoms is a viral infection, then the patient will continue to receive unnecessary treatment because a rapid antigen detection test or throat culture will likely be positive repeatedly. Furthermore, because carriers are not precluded from acquiring new emm types while they are carriers, they may indeed be at risk of acute rheumatic fever if a new acquisition occurs.
Thus, carriers should be tested and treated as if they have new GAS infection when they have symptomatic episodes of pharyngitis, especially without viral symptoms, and a test is positive for GAS.
Finally, repeated episodes of pharyngitis accompanied by a positive test for GAS may cause much consternation among parents and patients. The patient may have missed significant time in school or childcare, the parent may have missed work, and invasive procedures such as tonsillectomy may be requested by parents or primary care providers.
An attempt at eradicating carriage may provide reassurance in this scenario. Despite decades of research, the GAS carrier state remains poorly understood. A working definition used in some clinical trials and practical to clinicians is the patient who harbors GAS in the pharynx after adherence to an appropriate antibiotic for an episode of pharyngitis presumed to be caused by GAS. Carriers have little risk for nonsuppurative complications of GAS and though they may possibly transmit the organism to others, the degree of communicability is less than from acutely infected individuals.
Most children who are carriers do not require treatment, but an attempt at eradication of the carrier state may be of benefit in select children. Potential conflicts of interest. All authors: No reported conflicts. Google Scholar. Google Preview. Oxford University Press is a department of the University of Oxford.
It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume 3. Article Contents Abstract. Editor's Choice. DeMuri , Gregory P. Corresponding Author : Gregory P. Someone with strep throat may also have a rash known as scarlet fever also called scarlatina.
A sore throat that starts quickly, pain with swallowing, and fever are some of the common signs and symptoms of strep throat. Anyone can get strep throat, but there are some factors that can increase the risk of getting this common infection.
Strep throat is more common in children than adults. It is most common in children 5 through 15 years old. It is rare in children younger than 3 years old. Adults who are at increased risk for strep throat include:. Close contact with another person with strep throat is the most common risk factor for illness. For example, if someone has strep throat, it often spreads to other people in their household. Infectious illnesses tend to spread wherever large groups of people gather together.
Crowded conditions can increase the risk of getting a group A strep infection. These settings include:. Only a rapid strep test or throat culture can determine if group A strep is the cause.
A doctor cannot tell if someone has strep throat just by looking at his or her throat. A rapid strep test involves swabbing the throat and running a test on the swab. The test quickly shows if group A strep is causing the illness. If the test is positive, doctors can prescribe antibiotics.
If the test is negative, but a doctor still suspects strep throat, then the doctor can take a throat culture swab.
A throat culture takes time to see if group A strep bacteria grow from the swab. While it takes more time, a throat culture sometimes finds infections that the rapid strep test misses.
Such procedures increase the proportion of positive cultures that are often missed with simpler, standard office methods. The question arises whether less sensitive bacteriologic methods result in missed significant clinical disease. We suggest that an appropriate standard would be the methods of Denny et al 19 and Wannamaker et al, 20 which established the value of penicillin therapy in eradication of GABHS from the tonsillopharynx as a primary prevention technique for acute rheumatic fever.
In those studies, the culture methods were more similar to those routinely used in our office practice. The GABHS carriers in our study population had higher colony counts than often reported; however, the relation between colony count and carrier status has been previously challenged.
There continues to be recognized disagreement with regard to the significance of the carrier state. They showed in their institutional study setting that the carrier could be an important vector in these infections and that the frequency of spread and resulting disease was often characteristic of a specific strain of GABHS. However, during certain other periods of observation, major and minor outbreaks occurred usually by strains of GABHS that were new to the institution; several of these outbreaks were introduced by carriers.
Asymptomatic spread of GABHS from a streptococcal carrier within a family has been described to occur. Since we did not M and T type our strains in this study, we are unable to comment on strain variation presented in our carrier population. In the acute GABHS—infected patients who received antibiotic treatment, acquisition of a new strain vs persistence of the original infecting strain may occur.
When serotyping of strains is done, our group 34 and others 20 , 35 have previously shown that after antibiotic treatment, about two thirds of the isolates will be the same serotype and one third will be new acquisitions. We elected not to measure antistreptolysin O and anti-DNase B titers in our study population. Some of the patients in the antibiotic-treated population of our study could have been carriers.
It has been suggested that the superiority of treatment with cephalosporins and perhaps macrolides in comparison with penicillin in bacteriologic outcome following acute GABHS tonsillopharyngitis is due to enrollment of carriers in comparative studies and due to more effective eradication of the carrier state with the broader spectrum agents.
The carrier rate in our practice is 2. Thus, our results show that the GABHS carrier state follows penicillin treatment more often than following cephalosporin or macrolide treatment, but other, much larger factor s 41 must contribute to differences in eradication rates among these therapies. Anne B. Corresponding author: Michael E. Editor's Note: Well, here you have it folks. Data from the "real world" Rochester qualifies that differs from classical information.
Which world do you practice in? DeAngelis, MD. Arch Pediatr Adolesc Med. Coronavirus Resource Center. Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy Continue. Save Preferences. Privacy Policy Terms of Use. Twitter Facebook. This Issue. Citations View Metrics.
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