Streptococcal Pharyngitis in Paediatric Primary Care: Clinical Characteristics, Recurrences, Complications, and Antibiotic Management

INTRODUCTION: Group A streptococcal (GAS) pharyngitis is the most common bacterial infection in childhood. National and international guidelines consistently recommend narrow-spectrum beta-lactams as first-line therapy; however, variability in outpatient management remains substantial. This study aimed to characterize the clinical features, recurrence patterns, and complications of paediatric group A streptococcal pharyngitis in primary care. METHODS: We performed a prospective, multicenter observational study coordinated by the Italian Society of Primary Care Paediatrics from August 2024 to June 2025. Sixty-six primary care paediatricians across all Italian regions enrolled children aged 1-18 years with microbiologically confirmed GAS pharyngitis with positive rapid antigen detection test. Collected data included demographics, clinical presentation, antibiotic therapy, recurrences, complications, and microbiological findings. Statistical analyses were conducted using chi-square or Fisher's exact tests, with p < 0.05 considered statistically significant. RESULTS: A total of 1464 episodes of GAS pharyngotonsillitis were documented in 1187 children. Among the 1187 children included in the study, 342 (28.8%) were aged < 5 years and 509 (42.9%) were aged 5-8 years. Most cases (99.5%) were uncomplicated, while 7 (0.5%) developed complications, including sinusitis, peritonsillar abscess, and one case of post-streptococcal glomerulonephritis; three patients required hospitalization. Recurrent infections, whether early (≤ 4 weeks) or late, were not associated with a higher risk of complications. Amoxicillin was prescribed as first-line therapy in 77.5% of uncomplicated episodes, and overall, 51.5% of cases were fully adherent to guideline recommendations. Non-adherence was attributable to inappropriate antibiotic selection in 22.9% of episodes and to an incorrect duration of antibiotic therapy in 25.6% of episodes. CONCLUSIONS: Paediatric GAS pharyngitis in this nationwide cohort was predominantly benign, with rare complications. Recurrences was not associated with complication risk. Nonetheless, the discrepancy between Italian guideline recommendations and the real-world use of broad-spectrum antibiotics at first episodes underscores the need to strengthen antimicrobial stewardship in primary care.