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patients for strep throat when they have only nonspecific symptoms like
abdominal pain or prominent upper respiratory symptoms, may result in a
positive test, leading to unnecessary use of antibiotics, and contributing to
increased side effects, costs, and resistance.
While no sign or symptom is specific or sensitive enough to diagnose GAS, a
number of clinical decision rules (CDRs) have been developed to aid diagnosis
and limit unnecessary diagnostic testing. The Centor criteria are perhaps the best
known and consist of four signs, with one point each given for fever, tonsillar
exudates, tender anterior cervical nodes, and absence of cough. Patients with a
score of 0 or 1 are presumed to have viral pharyngitis and require no further
testing, whereas higher scores are progressively more likely to reflect GAS
infection. The Modified Centor score (McIsaac score) adjusts for patient age,
reflecting the higher incidence of GAS among children age 5 to 15 years.
To prevent the delayed sequela of rheumatic fever, the accurate diagnosis of
streptococcal pharyngitis assumes great importance. Generally, symptomatic
therapy suffices in the patient with a negative rapid test, although the physician
may elect to initiate therapy, usually with a penicillin (penicillin V or amoxicillin)
but occasionally with a cephalosporin or macrolide, while awaiting the results of
the throat culture in selected cases with highly suggestive clinical features. It is
worth noting that the macrolides will not treat Fusobacterium, which rarely
causes sore throat but is the primary pathogen in Lemierre syndrome.
Suggested Readings and Key References
Centor RM, Witherspoon JM, Dalton HP, et al. The diagnosis of strep throat in
adults in the emergency room. Med Decis Making 1981;1(3):239–246.
Fine AM, Nizet V, Mandl KD. Improved diagnostic accuracy of group A
streptococcal pharyngitis with use of real-time biosurveillance. Ann Intern Med
2011;155(6):345–352.
Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac
scores to predict group A streptococcal pharyngitis. Arch Int Med
2012;172(11):847–852.
Fine AM, Nizet V, Mandl KD. Participatory medicine: a home score for

streptococcal pharyngitis enabled by real-time biosurveillance. Ann Intern Med
2013;159(9):577–583.
Fleisher GR, Lennette ET, Henle G, et al. Incidence of heterophil antibody
responses in children with infectious mononucleosis. J Pediatr
1979;94(5):723–728.