The “Strep” Holiday Is Over!

It is common practice, found frequently in emergency department discharge instructions and always mandated by school nurses, that a child who is diagnosed with “strep throat” must be treated with antibiotics for 24 hours or more before returning to school. The rationale, although without foundation, is that this will reduce the risk of disease transmission. Even the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) still make this recommendation.

According to the CDC, “people with strep throat should stay home from school or day care until they have taken antibiotics for at least 24 hours.” The AAP states that “children with strep throat also need to be taking an oral antibiotic for 24 hours before they can return [to school].”¹

Let’s consider for a moment that a given child actually has pharyngitis or tonsillitis caused by group A beta-hemolytic streptococcus. Is the 24 hour-rule worth following or just pediatric folklore?

First, we can probably assume, to a certain degree, in each of our practices that some percentage of those we diagnose with strep, particularly using the Centor or McIsaac (modified Centor including adding one point for age younger than 15 years and subtracting one point for age older than 45 years) criteria, don’t even have the disease. So, a small, but not insignificant, percentage of our patients are held to this questionable standard, protecting their classmates from a virus. Second, the socioeconomic considerations shouldn’t be discounted. Abolishing this standard would result in better school attendance and avoidance of missed work for parents. Fairfax County, Virginia, estimated the value of a lost working day to be $427.23.1

Finally, and most important, Schwartz et al debunked this myth in 2015.1 They noted in their study that there was sufficient evidence from three studies in 1985 to challenge this practice. Small numbers—0 percent, 3 percent, and 5 percent, respectively—of these 264 patients had persistent positive cultures 18 to 24 hours after initiating antibiotics. Yet the age-old recommendations were never changed.

The Schwartz study, conducted at Inova Children’s Hospital in Virginia, revisited this topic, evaluating whether a single dose of amoxicillin for group A strep pharyngitis would allow return to school in 12 to 23 hours. A total of 111 patients, ages 2 to 17 years, who had sore throats, pharyngeal erythema, and a positive rapid antigen test for group A strep were all given a single dose of amoxicillin (50 mg/kg) and then randomized to two groups, with group A receiving an additional dose at least one hour prior to the arrival for the day two office visit and group B receiving no additional doses prior to the return visit. All patients returned the next morning, day two, to obtain a repeat rapid antigen test and a throat culture. Six patients in group A and four patients in group B had a positive rapid antigen test (confirmed with culture). Thus, 91 percent had undetectable levels 11 to 23 hours post treatment following a single dose of amoxicillin. The authors concluded that if children receive their first dose of amoxicillin 12 hours (5 p.m.) prior to the next school day and they are afebrile and improving, they should be allowed to return to school.