About Us
Our Services
New Patients
Forms & Policies
Medical Resources
   Medical Conditions
      Abdominal Pain, Recurrent
      Acute Ear Infections and Your Child
      Acute Lymphoblastic Leukemia
      Acute Otitis Media
      Acute Strep Throat
      ADHD and Your School-aged Child
      Allergies in Children
      Anemia and Your Young Child
      Anesthesia and Your Child
      Ankle Sprain Treatment (Care of the Young Athlete)
      Antibiotics and Your Child
      Asthma and Exercise (Care of the Young Athlete)
      Asthma and Your Child
      Asthma Triggers
      Atopic Dermatitis (Eczema)
      Attention-Deficit Hyperactivity Disorder
      Attention-Deficit Hyperactivity Disorder (ADHD)
      Breast Enlargement, Premature
      Breath-Holding Spells
      Bronchiolitis and Your Young Child
      Care of the Premature Infant
      Celiac Disease
      Chickenpox Immunization
      Chickenpox Vaccine, The
      Coarctation of the Aorta
      Common Childhood Infections
      Congenital Hip Dysplasia
      Constipation and Your Child
      Coxsackie A16
      Croup and Your Young Child
      Croup: When Your Child Needs Hospital Care
      Crying and Your Baby: How to Calm a Fussy or Colicky Baby
      Cyclic Vomiting Syndrome (CVS)
      Developmental Dysplasia of the Hip
      Diabetic Mother, Infant of
      Diaper Rash
      Diarrhea and Dehydration
      Diarrhea, Vomiting, and Water Loss (Dehydration)
      Ear Infection
      Ear Infections
      Eating Disorders
      Eczema (Atopic Dermatitis)
      Enlarged Lymph Nodes
      Erythema Multiforme
      Eye Problems Related to Headache
      Febrile Seizure
      Febrile Seizures
      Fetal Alcohol Syndrome
      Fever and Your Child
      Fifth Disease
      Fifth Disease (Erythema Infectiosum)
      Flu, The
      Food Allergies and Your Child
      Food Born Illnesses
      Fragile X Syndrome
      Gastroenteritis, Viral
      Gastroesophageal Reflux
      Guide to Children's Dental Health, A
      Hand Foot and Mouth
      Hand-Foot-and-Mouth Disease
      Head Lice
      Headache Related to Eye Problems
      Hepatitis A
      Hepatitis A Immunization
      Hepatitis B
      Hepatitis B Immunization
      Hepatitis C
      Hib Immunization
      High Blood Pressure
      Hip Dysplasia (Developmental Dysplasia of the Hip)
      How to Take Your Child's Temperature?
      Infant of a Diabetic Mother
      Infectious Mononucleosis
      Influenza Immunization
      Inhaled and Intranasal Corticosteroids and Your Child
      Kawasaki Syndrome
      Language Development in Young Children
      Lead Poisoning
      Lung Hypoplasia
      Lyme Disease
      Mental Health
      Middle Ear Fluid and Your Child
      MMR Immunization
      Molluscum Contagiosum
      Obesity in Childhood
      Osgood-Schlatter Disease
      Otitis Media, Acute
      Pneumococcal Conjugate Immunization
      Pneumonia and Your Child
      Polio Immunization
      Premature Thelarche
      Prematurity, Retinopathy of
      Pulmonary Hypertension
      Pulmonary Hypertension (PPH & SPH)
      Retinopathy of Prematurity
      Rheumatic Fever, Acute
      Ringworm (Tinea)
      Rubella (German Measles)
      Safety of Blood Transfusions
      Seasonal Influenza (Flu) 2014–2015
      Separation Anxiety
      Sinusitis and Your Child
      Sleep Apnea and Your Child
      Speech Development in Young Children
      Stevens-Johnson Syndrome
      Strep Throat
      Strep Throat-Acute
      Strep Throat-Recurrent
      Stuttering and the Young Child
      Swine Flu
      Swine Flu (H1N1) FAQ
      Swine Flu (H1N1) Vaccine
      Swollen Glands
      Tear Duct, Blocked
      Tetralogy of Fallot
      Thyroid Problems
      Tinea (ringworm infection)
      Tonsils and the Adenoid
      Toxic Shock Syndrome
      Turner Syndrome
      Type 2 Diabetes: Tips for Healthy Living
      Underdeveloped Lungs
      Urinary Tract Infection
      Urinary Tract Infections in Young Children
      Varicella or Chickenpox
      Varivax Immunization
      Vesicoureteral Reflux
      Whooping Cough (Pertussis)
      Wilson Disease
   What's Going Around?
Contact Us

Practice News

Anywhere Family Practice is thrilled to announce the addition of Dr. Julie Johnson to our team.
We will be transitioning to a new patient portal in April. Watch for new updates on this website!

Is Your Child Sick?TM


Are You Sick?

Strep Throat-Recurrent

by Michael E. Pichichero, M.D.
Professor of Microbiology and Immunology, Pediatrics and Medicine
University of Rochester Medical Center
Elmwood Pediatric Group

If a child or a teenager has repeated episodes of streptococcal tonsillitis or pharyngitis ("strep throat"), several possible explanations should be considered.

Are the sore throats actually caused by strep?

Many physicians diagnose strep throat infections based on a patient's history and an examination. However, without the aid of a throat culture or a rapid strep detection test, recurrent strep throat infections are difficult to accurately diagnosis. The complaint of a sore throat is frequent in the primary care practice setting. Yet, at the peak of the strep throat infection season (late fall through early spring), strep is the cause of a sore throat in less than 30% of children and 10% of teenagers.

Therefore, strictly on a percentage basis, physicians, who diagnose strep in the majority of patients with a sore throat, over-diagnose 90% of teenagers and 70% of children. Even in a patient with typical symptoms-a fever, a red throat with yellow pus on the tonsils, swollen and tender neck lymph glands, and the absence of a runny nose and a cough-misdiagnosis is common. In one study, an overestimate of the probability of a positive strep culture was observed for 81% of the patients.

To accurately diagnose strep throat infections, physicians use throat cultures (the gold standard) or rapid strep detection tests. Rapid strep detection tests improve the accuracy of diagnosing strep throat infections. The accuracy of rapid strep detection tests varies between products, but the main variable is in the carefulness of performing the test. The critical factor is attention to detail and strictly following the manufacturers' guidelines for the test.

Table 1.

Causes of Pharyngitis

Peak Incidence (%)
Cause Children Adults
Bacterial 30 to 40 5 to 10
GAS 28 to 40 5 to 9
Group C, G, or F Streptococcus 0 to 3 0 to 18
N gonorrhoeae 0 to 0.01 0 to 0.01
A haemolyticum 0 to 0.05 0 to 10
M pneumoniae 0 to 3 0 to 10
C pneumoniae 0 to 3 0 to 9
Viral 15 to 40 30 to 60
Idiopathic 20 to 55 30 to 65
Data compiled from Reference 1.


Did the patient finish the prescribed antibiotic?

Patients often do not finish the complete treatment of antibiotics. The symptoms of strep throat end quickly with antibiotics; patients feel completely better within two to three days after beginning treatment. Because of this improved well being, parent motivation to continue the medicine diminishes.

Studies from hospital-based clinics and private practices have confirmed that as many as 50% of patients have stopped taking penicillin for strep throat by the third day, 70% by the sixth day, and over 80% by the ninth day. In the same populations, over 80% of the families claimed that all of the prescribed medicine had been taken.


Is the problem antibiotic resistance or tolerance?

The following antibiotics-penicillin, amoxicillin, and cephalosporins (i.e., Keflex, Duricef, Ceclor, Lorabid, Ceftin, Cefzil, Vantin, Suprax, Cedax, and Omnicef)-are effective in treating strep throat infections. Infrequently, strep throat infections are resistant to Erythromycin, clarithromycin (Biaxin), and azithromycin (Zithromax).


Is the patient experiencing repeated exposure to strep?

Some patients are effectively treated for a strep infection with antibiotics, only to return to an environment where the infection continues to circulate. The patient then becomes re-infected and returns to the physician with a recurrent strep throat infection. Certain circumstances-crowded working conditions, schools, day care settings, and larger families-more frequently transmit strep. One small study and one case report have suggested that, in rare instances, dogs also may be carriers of strep; however, other investigations have not corroborated this possibility.


Is the patient not responding to antibiotics?

Even when all strep infections are laboratory confirmed with throat cultures or rapid strep detection tests, and the antibiotic is finished, failure to respond to treatment still occurs. The highest treatment failure rates observed are with penicillin; about two-thirds of presumed strep throat infections are treated with either penicillin or amoxicillin. Penicillin and amoxicillin treatment failures vary geographically, and the incidence of penicillin treatment failures for strep throat infections may be rising. Patients most likely to experience a penicillin or amoxicillin treatment failure are those who have recently received treatment with these drugs and are then retreated with the same antibiotic.


Has prior antibiotic therapy eliminated protective throat bacteria?

Prominent, normal bacteria of the throat include another type of streptococci (alpha hemolytic). These bacteria make natural antibiotic substances (to provide an advantage for themselves) in the throat. Penicillin or amoxicillin therapy may change the natural environment for throat bacteria by killing these alpha hemolytic streptococci; their elimination provides an opportunity for disease-causing strep to gain access to the throat cells. This is another reason for patients to avoid unnecessary antibiotic use.


Has early, prompt antibiotic treatment suppressed natural immunity?

With the availability of rapid strep detection tests and the publication of several convincing studies that describe faster clinical improvement from prompt treatment, many physicians have been prescribing antibiotics sooner after diagnosing strep throat infections.

Immediate penicillin treatment has been shown to be a cause of recurrent strep infections. Early antibiotic treatment suppresses the natural immune response to strep. Delaying antibiotic therapy for two days after the onset of a sore throat allows an immune response to develop, which may reduce the chance of a relapse or recurrence of strep throat infections.

Two similar studies compared immediate penicillin treatment with treatment delayed for 48 to 56 hours in 343 children with documented strep throats. Early antibiotic therapy produced a three-time increase in the frequency of recurrent infections as compared to those for whom treatment was delayed.

Table 2.

Recurrence Rates of Immediate versus Delayed Treatment of GAS Tonsillopharyngitis with Penicillin

Treatment Group (n)(%)*

Recurrent Acute GAS Pharyngitis

Immediate Treatment(n=70)

Delayed Treatment
(48 to 56 hr)

Early recurrence 32 (19) 14 (8) 0.006
Late recurrence 22 (13) 5 (3) 0.001
Total recurrence 54 (32) 19 (11) <.001
*Treatment groups compared by x2 of Fisher's exact test, as appropriate; data compiled from References 12 and 13.

A delay in treatment does not increase the risk of rheumatic fever since a delay of up to nine days from the onset of symptoms can be made. Nevertheless, for patients who appear severely ill or in times when highly infectious strains of strep are circulating, intentionally delayed treatment should not be considered.


Is the patient a strep carrier?

A positive throat culture or a rapid strep test alone cannot distinguish between the patient with strep throat and the patient with an acute viral sore throat who is a chronic strep carrier. The strep carrier has a positive throat culture, but does not show symptoms of an acute strep infection or show a rise in strep antibody levels. In clinical practice, identifying a strep carrier is problematic.

Following treatment, the patient needs to be seen again to determine whether strep is present when the patient does not have a sore throat. In addition, antibody levels need to be drawn when the patient has a sore throat and then drawn again four to six weeks later to measure strep antibodies. If antibiotic therapy has been given to treat prior symptoms, it may suppress the antibody rise, thereby negating the usefulness of this test.

Table 3.

Short-Course Treatment of Streptococcal Phayngitis

Bacteriologic Cure

Duration of

Cephalosporin or Azithromycin

Penicillin (10 days)

Cefuroxime axetil 4 82/90 (96%) 77/80 (96%)
Cefadroxil 5 87/104 (84%) 93/105 (89%)
Cefpodoxime proxetil 5 59/61 (97%) 49/52 (94%)
Cefpodoxime proxetil 5 79/82 (96%) 64/68 (94%)
Cefuroxime axetil 4 83/97 (88%) 90/103 (87%)
Cefpodoxime proxetil 5 112/121 (93%) 101/130 (78%)
Azithromycin 5 167/176 (95%) 130/187 (77%)
Azithromycin 5 139/147 (95%) 88/127 (69%)
Data compiled from Reference 15.


What antibiotic should be selected?

Many antibiotics---such as penicillin-can be used to treat recurrent strep throat infections.

Clindamycin or rifampin, in combination with a second antibiotic, such as penicillin, amoxicillin, or a cephalosporin, has been used to treat acute, recurrent, and carrier strep throat infections. Routine use of clindamycin is not advocated because diarrhea is a rare, but significant, side effect. Rifampin must be used with a second antibiotic because strep will rapidly become resistant to it when it is given as a single therapy. Patients should be advised that rifampin produces orange discoloration of the urine and tears (permanently staining contact lenses).

Oral cephalosporins (Keflex, Duracef, Ceclor, Lorabid, Ceftin, Cefzil, Suprax, Vantin, Omnicef, and Cedax) have gained widespread use in treating recurrent strep throat infections. When cephalosporin antibiotics are used to treat strep throat infections, a failure occurs less than 5% of the time; however, they are more expensive than penicillin or amoxicillin.

Amoxicillin/clavulanic acid (Augmentin) has been evaluated to treat strep throat with superior or equivalent results in comparison to penicillin.

Table 4.

Penicillin versus Cephalosporins in the Treatment of Streptococcal Pharyngitis

Treatment Regimen


Bacteriologic Failure Rate (%)


Clincial Failure Rate

Cephalosporins 1290 8.01 926 5.02
Penicillins 1169 16.01 865 11.02
1p = 0.0001
2p < 0.001
Data compiled from Reference 8.


Should a tonsillectomy be performed?

If a patient has six to seven recurrent strep throat infections over a one-to two-year time span, then a tonsillectomy should be considered after consulting with your primary care physician. Families should be advised that the procedure reduces the frequency of sore throats, and, specifically, strep throats, for two to three years after surgery.


About the Author

Dr. Michael E. Pichichero is currently a Professor of Microbiology and Immunology, Pediatrics and Medicine at the University of Rochester in Rochester, NY.

A graduate of the University of Rochester School of Medicine, Dr. Pichichero completed his postgraduate pediatric residency at the University of Colorado in Denver, followed by a Chief Residency and two fellowships resulting in board certification in Pediatrics, in Adult and Pediatric Allergy and Immunology and in Pediatric Infectious Disease.

Dr. Pichichero is a partner in the Elmwood Pediatric Group where he continues to practice in primary care and as a subspecialist consultant.

A recipient of numerous awards and a member of most professional societies in his fields of interest, Mike has over 300 publications in infectious diseases, immunology, and allergy.

His major practice and research interests are in vaccine development, streptococcal infections, and otitis media: in each of these areas he is a prominent international authority.

Copyright 2012 Michael E. Pichichero, M.D., All Rights Reserved