By Megan McGrath PharmD Candidate,

Streptococcal pharyngitis is an infection caused by Streptococcus pyogenes (otherwise known as group A streptococcal or GAS). Children 3 to 14 years are most likely to have these infections with 93.2 cases per 1000 persons 3 to 9 years old and 40.9 cases per 1000 persons 10 to 18 years old.¹ 21.5% of all acute pharyngitis cases thought to be caused by GAS.¹ GAS pharyngitis typically presents with a painful sore throat, swollen tonsils, and fever. Symptoms of cough and congestion instead suggest viral etiology.

Historically, the determination to test for streptococcal pharyngitis relied on clinical presentation and provider judgment. In recent years, however, clinical screening tools have been used more frequently to provide a validated score determining the likelihood of streptococcal pharyngitis.

Colonization with GAS in the throat is common in children; up to 20% may be asymptomatically colonized. Colonization rates decrease with age, with an estimated 5% of adults carrying GAS.² The ideas is that screening tools can help prevent testing and thus reduce false positives from testing those colonized with GAS but not experiencing acute infection. The biggest issue with over-testing is that it can lead to unnecessary antibiotic prescribing, whereas appropriately testing patients with a high likelihood of GAS pharyngitis is important to prevent complications from the disease. Acute rheumatic fever, a rare complication of GAS pharyngitis, occurs in about 10 cases per 100,000 persons per year in the US, when antibiotics are either delayed or not utilized to treated GAS pharyngitis.³ The risk of this complication is higher in children (versus adults) and factors such as overcrowded living environment and limited healthcare access can further increase their risk.⁴

Streptococcal Pharyngitis Guideline Updates

In 2025, the Infectious Diseases Society of America(IDSA) released updated clinical practice guideline on GAS pharyngitis.⁵ This update focuses on risk assessment of streptococcal pharyngitis and determining the likelihood of infection requiring testing. It does not provide changes in disease treatment. The three main screening tools they discuss are Centor, McIsaac, and FeverPAIN, summarized below in Table 2.⁵ Each of these scoring rubrics consist of questions regarding a patients’ physical exam and clinical presentation compiled into a score to stratify the risk of the patient having GAS pharyngitis into a low (1-13%), moderate (21-38%) or high (51-69%) probability category.⁵ The tools are approved for use in patients greater than 3 years old with an onset of acute pharyngitis within the past 3 days. All 3 scoring systems evaluate absence of cough, tonsil appearance and presence of fever in their algorithms. Centor and McIsaac also evaluate presence of swollen or tender cervical lymph nodes.^5-7 McIsaac was adapted from the Centor tool to be validated specifically in children and is the only tool that considers age with an added point for ages 3-14 years old. ^5-7 These tools are most useful in identifying patients with a low probability of GAS infection who may not require testing. The McIsaac and Centro have more evidence as noted by a recent meta-analysis.

The guideline discussed that in the meta-analysis, McIsaac and Centor scoring were evaluated they were most useful for ruling out GAS infection than determining if the patient had the infection.^5,8 So, if a child screens as low probability, testing is not recommended (negative predictive values with scores of 0 were 7.1 and 8.1%).^5,8   Patients with moderate to high scores should undergo testing for GAS pharyngitis to ensure appropriate treatment and reduce the risk of complications.⁵

While clinical prediction tools can help to differentiate patients and reduce unnecessary testing, they also introduce the potential risk of missed GAS pharyngitis, which could increase the likelihood of progression to rheumatic fever if left untreated and infected with rheumatogenic strain.⁴ Although this risk is low, it is important to recommend to those who are not indicated for testing to return for additional evaluation if they do not improve in a few days to prevent significant delays in treatment.

Recommended Antibiotic Treatments

The IDSA GAS guidelines for recommended treatments have not been updated recently but are included for completeness.⁹  Most common treatments are outlined below with alternative options summarized in Table 1.⁹ First line treatments for streptococcal pharyngitis include:

       Penicillin or Amoxicillin as Firstline GAS Pharyngitis Treatment

• Both meet antimicrobial stewardship principles of narrow spectrum and are low cost and easy for patients to access.
• For young children, amoxicillin is the drug of choice due to its favorable taste and multiple available dosage forms (e.g., suspension, chewable, capsule)
• Recommended amoxicillin dosing is different for GAS pharyngitis versus other infections it is amoxicillin 50 mg/kg/day divided in 1-2 daily doses (max 1000 mg/day) for 10 days.⁹

For GAS pharyngitis, due to the rare cases of rheumatic fever, it has been difficult to demonstrate if a shorter course would have the same benefit as 10 days, so at this point, the 10-day treatment duration continues to be recommended, despite many patients feeling better after about 3 days of treatment. Until there is new evidence or recommendations, GAS pharyngitis, remains one of the small number of conditions where it is still important to advise patients to complete their full antibiotic course.

Table 1: Alternative Antibiotic Agents for GAS Pharyngitis^9-11

Antibiotic Agent	Reason for Use
IM Penicillin G Benzathine	Technically considered a first-line treatment Considered for those with significant vomiting, impaired oral intake, or adherence concerns (1 time dose) Currently, availability is limited by manufacturer backorders and FDA product recalls. Thus, use may be restricted to specific populations and indications.
Cephalexin	Alternative for some penicillin allergic Shares a similar side chain to amoxicillin- low cross sensitivity risk. Consider in patients with non-severe amoxicillin allergy.
Clindamycin	Alternative for penicillin and cephalosporin allergic Since no similarity can be used in those with severe allergies Increased cost and lack of preferred taste for liquid formulation are negatives that should be considered

Implications for Pharmacists

Pharmacists in ambulatory settings should be aware of these clinical screening tools to aid in their practice. Currently 8 states in the US allow pharmacists to test and treat for GAS pharyngitis independently, and many others permit this under collaborative practice agreements.¹² When pharmacists bring these services into practice, the largest stewardship benefit is applying screening tools to best interpret which patients should be tested and thus limiting antibiotics prescribed to when most likely to provide benefit. It is about striking the right balance: avoiding unnecessary testing while still identifying patients early enough to intervene and prevent complications.  Additional research is needed to determine which clinical prediction tool will be the gold standard in practice. McIssac and Centor have been well validated, but FeverPAIN has less evidence, might be easier to implement, ease and convenience is important considerations for pharmacists working in a busy ambulatory setting. Incorporating these tools into practice can ensure patients are assessed appropriately with testing, treatment, and follow-up is consistently applied. When done correctly, implementation of these tools into practice is expected to potentially result in about 48% less inappropriate antibiotic treatments.⁶

Table 2: Summary of Clinical Prediction Tools for those > 3 years old (adapted from IDSA guideline) ^5-7

Clinical Features	Centor & McIsaac	FeverPAIN
Duration of Symptoms	Do not use rubric if symptoms longer than 3 days	Symptom onset less than 3 days: 1 pt
Age	McIsaac:                             Centor: 3-14: 1 pt                             n/a 15-44: 0 pt >45: -1 pt	n/a
Physical Exam	Swollen or purulent tonsils: 1 pt Tender cervical lymph nodes: 1 pt	Swollen tonsils- 1 pt Exudative tonsils- 1 pt
No Cough	Yes, no cough: 1 pt	Yes, no cough or cold: 1 pt
Fever (>100.4°F)	Yes: 1 pt	If yes in prior 24 hours: 1 pt

Score Interpretation: Low Risk: 0-1 = generally no testing; Moderate – High Risk: 2-5 = testing indicated

Megan McGrath is a Doctor of Pharmacy candidate at the University of Connecticut. This post was written as part of her Advanced Pharmacy Practice Experience under the guidance of her professor, Jennifer Girotto PharmD, BCPPS, BCIDP, who also reviewed and edited the piece.

References

1. Lewnard JA, King LM, Fleming-Dutra KE, Link-Gelles R, Van Beneden CA. Incidence of pharyngitis, sinusitis, acute otitis media, and outpatient antibiotic prescribing preventable by vaccination against group A streptococcus in the united states. Clin Infect Dis. 2021;73(1):e47–e58. doi: 10.1093/cid/ciaa529.
2. CDC. Transmission in and between facilities. Centers for Disease Control Web site. https://www.cdc.gov/group-a-strep/php/ltcf-toolkit/transmission.html. Updated 2025. Accessed February 19, 2026.
3. Chowdhury MS, Koziatek CA, Tristram D, Rajnik M. Acute rheumatic fever. In: StatPearls. Treasure Island (FL): StatPearls Publishing LLC; 2025.
4. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Circulation. 2009;119(11):1541–1551. https://doi.org/10.1161/CIRCULATIONAHA.109.191959. doi: 10.1161/CIRCULATIONAHA.109.191959.
5. Linder JA, Watson ME, Wessels MR, et al. 2025 clinical practice guideline update by the infectious diseases society of america on group A streptococcal (GAS) pharyngitis: Risk assessment using clinical scoring systems in children and adults. Clin Infect Dis. 2025. doi: 10.1093/cid/ciaf668.
6. McIsaac WJ, White D, Tannenbaum D, Low DE. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75–83.
7. Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239–246. doi: 10.1177/0272989X8100100304.
8. Willis BH, Coomar D, Baragilly M. Comparison of centor and McIsaac scores in primary care: A meta-analysis over multiple thresholds. Br J Gen Pract. 2020;70(693):e245–e254. doi: 10.3399/bjgp20X708833.
9. 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(10):86. doi: 10.1093/cid/cis629.
10. Bachmann LH, Stoner B. Bicillin L-A. Centers for Disease Control(CDC) Web site. https://www.cdc.gov/sti/php/from-the-director/2025-07-bicillin-recall.html. Updated 2025. Accessed February 19, 2026.
11. Wheeler M. Penicillin G benzathine. American Society of Health-system Pharmacists(ASHP) Web site. https://www.ashp.org/drug-shortages/current-shortages/drug-shortage-detail.aspx?id=909. Updated 2026. Accessed February 19, 2026.
12. NASPA. Pharmacist prescribing: Test and treat. https://naspa.us/resource/pharmacist-prescribing-for-strep-and-flu-test-and-treat/. Updated 2025. Accessed February 19, 2026.

 

 

By Nicole Pietraszewski PharmD Candidate,

Community acquired pneumonia (CAP) is the cause of about 1.5 million pediatric medical visits each year and remains the second-leading cause of pediatric hospitalizations in the United States.¹ The 2011  Pediatric Infectious Disease Society and Infectious Diseases Society of America (PIDS/IDSA) guideline for pediatric CAP, currently archived, recommends a 10-day treatment course for most patients, as available evidence at the time supported that duration.² Although the guideline acknowledged that shorter courses might be effective for uncomplicated outpatient cases and could help limit resistance, it has not been updated to reflect more recent data supporting shorter treatment durations.²

Importantly, the 2024 Report of the Committee on Infectious Diseases of the American Academy of Pediatrics (AAP Red Book)  currently recommends a 5-day treatment duration for uncomplicated CAP, while recognizing that longer courses remain appropriate for complicated infection.³ This guidance sets the stage for pharmacists to help standardize shorter, evidence-based CAP treatment durations across outpatient settings.

What do different guidelines recommend for pediatric outpatient CAP?

Other guidance has moved toward shorter (3-5 day) antibiotic courses for outpatient pediatric CAP.^4,5 Both the World Health Organization (WHO) and the United Kingdom’s National Institute for Health and Care Excellence (NICE) published guidelines in 2024 and 2025, and respectively recommend this short duration.^4,5

What evidence is there for short-duration treatment for pediatric outpatient CAP?

A large meta-analysis published compared short-duration treatment (3-5 days) versus long-duration treatment (5-10 days) antibiotic therapy in children (<18 years old) with CAP.¹ The analysis included 16 randomized controlled trials, published from inception to April 30, 2022, with a total of 12,774 patients.¹

Shorter antibiotic courses had similar outcomes as longer ones.¹ There was no significant difference found in the odds of clinical cure (n=7,298; OR 1.01, 95% CI 0.87 to 1.17), risk of treatment failure which included generally worsening or non-improving illness requiring treatment change, hospitalization (n=10,303; RR 1.06, 95% CI 0.93 to 1.21), mortality (n=9,058; RD 0.0%, 95% CI -0.2 to 0.1), or adverse effects (n=2,249; RR 0.75, 95% CI 0.44 to 1.28).¹ The subgroup analysis showed no differences by age, same or different drug class, and high or low income countries.¹

A more focused CAP meta-analysis included all high-income country trials namely CAP-IT, SCOUT-CAP, SAFER, and the 2014 Greenberg trial.^1,6 The meta-analysis, which is more applicable to US patients based on population and treatments, evaluated randomized controlled trials published from 2003 to 2022, concluded that 3-5 days was as safe and effective as 7-10 days in patients with uncomplicated CAP.⁶ It only included trials comparing beta-lactam therapies, consistent with PIDS/IDSA and AAP Red Book recommendations that amoxicillin is first-line for non-severe CAP.^2,3,6

Populations of Focused CAP Meta-Analysis

Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children with Community-Acquired Pneumonia: a randomized controlled trial (CAP-IT): children aged ≥ 6 months (6-24 kg) diagnosed with CAP and discharged within 48 hours on amoxicillin monotherapy7 3 vs 7 days of amoxicillin 35-50 mg/kg/day divided twice daily 3 vs 7 days of amoxicillin 70-90 mg/kg/day divided twice daily

Short- vs Standard-Course Outpatient Antibiotic Therapy for Community-Acquired Pneumonia in Children: a randomized controlled trial (SCOUT-CAP): children aged 6-71 months with outpatient uncomplicated CAP and prescribed amoxicillin, amoxicillin-clavulanate, or cefdinir all divided twice daily8 5 vs 10 days of amoxicillin 80-100mg/kg/day, amoxicillin-clavulanate 80-100mg/kg/day or cefdinir 12-16 mg/kg/day

Short-Course Antimicrobial Therapy for Pediatric Respiratory Infections: a randomized controlled trial (SAFER): children aged 6 months to 10 years with CAP that did not require hospitalization and prescribed amoxicillin monotherapy9 5 vs 10 days of amoxicillin 75-100 mg/kg/day divided three times daily

Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: a randomized controlled trial: children aged 6-59 months with CAP that did not require hospitalization10 3 vs 10 days of amoxicillin 80 mg/kg/day divided three times daily 5 vs 10 days of amoxicillin 80 mg/kg/day divided three times daily

This analysis found no difference between either treatment failure, defined as the need for antibiotic retreatment one month after initial course or hospitalization (n=1,541; RD -0.00, 95% CI -.03 to 0.02), or in adverse effects (n=1,194; RD -0.00, 95% CI -.05 to 0.05). ⁶

Overall, recent evidence supports 3 to 5 day beta-lactam treatment for children of at least 6 months old with uncomplicated CAP, primarily outpatient.

What does this mean for practice and what’s next?

Antimicrobial stewardship programs in the inpatient arena have demonstrated strong improvements in antimicrobial prescribing.  This strong evidence, specific to pediatric CAP, provides an opportunity for pharmacists in ambulatory settings (e.g., community, clinics, emergency departments) to improve review their current practice, and if warranted implement antimicrobial stewardship efforts to reduce routine prescribing to 3-5 day durations of amoxicillin for most pediatric outpatient CAP cases,

About the author: Nicole Pietraszewski, is a Doctor of Pharmacy candidate at the University of Connecticut. This post was written as part of her Advanced Pharmacy Practice Experience under the guidance of her professor, Jennifer Girotto PharmD, BCPPS, BCIDP, who also reviewed and edited the piece.

References

1. Gao Y, Liu M, Yang K, et al. Shorter versus longer-term antibiotic treatments for community-acquired pneumonia in children: A meta-analysis. Pediatrics. 2023;151(6):e2022060097. doi: 10.1542/peds.2022–060097. doi: 10.1542/peds.2022-060097.
2. Bradley JS, Byington CL, Shah SS, et al. Executive summary: The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the pediatric infectious diseases society and the infectious diseases society of america. Clin Infect Dis. 2011;53(7):617–630. doi: 10.1093/cid/cir625.
3. Systems-based treatment tableCommittee on Infectious Diseases, American Academy of Pediatrics, Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH, eds. Red book: 2024–2027 report of the committee on infectious diseases. American Academy of Pediatrics; 2024:0. https://doi.org/10.1542/9781610027373-TAB. Accessed 2/9/2026. 10.1542/9781610027373-TAB.
4. World Health Organization. Guideline on management of pneumonia and diarrhoea in children up to 10 years of age. 2024. https://iris.who.int/server/api/core/bitstreams/bddcc725-8ffd-4d38-bec4-d6ead2904911/content.
5. National Institute for Health and Care Excellence. Pneumonia: Diagnosis and
   management. 2025.
6. Kuitunen I, Jääskeläinen J, Korppi M, Renko M. Antibiotic treatment duration for community-acquired pneumonia in outpatient children in high-income countries-A systematic review and meta-analysis. Clin Infect Dis. 2023;76(3):e1123–e1128. doi: 10.1093/cid/ciac374.
7. Bielicki JA, Stöhr W, Barratt S, et al. Effect of amoxicillin dose and treatment duration on the need for antibiotic re-treatment in children with community-acquired pneumonia: The CAP-IT randomized clinical trial. JAMA. 2021;326(17):1713–1724. doi: 10.1001/jama.2021.17843.
8. Williams DJ, Creech CB, Walter EB, et al. Short- vs standard-course outpatient antibiotic therapy for community-acquired pneumonia in children: The SCOUT-CAP randomized clinical trial. JAMA Pediatr. 2022;176(3):253–261. doi: 10.1001/jamapediatrics.2021.5547.
9. Pernica JM, Harman S, Kam AJ, et al. Short-course antimicrobial therapy for pediatric community-acquired pneumonia: The SAFER randomized clinical trial. JAMA Pediatr. 2021;175(5):475–482. doi: 10.1001/jamapediatrics.2020.6735.
10. Greenberg D, Givon-Lavi N, Sadaka Y, Ben-Shimol S, Bar-Ziv J, Dagan R. Short-course antibiotic treatment for community-acquired alveolar pneumonia in ambulatory children: A double-blind, randomized, placebo-controlled trial. Pediatr Infect Dis J. 2014;33(2):136–142. doi: 10.1097/INF.0000000000000023.