Coverage Policy Manual
Policy #: 2024053
Category: Laboratory
Initiated: November 2024
Last Review: October 2024
  Beta-Hemolytic Streptococcus Testing
Description:
Streptococcus are Gram-positive, catalase-negative bacteria that are further divided into α-hemolytic, such as S. pneumoniae and S. mutans; β-hemolytic, such as S. pyogenes (Group A), S. agalactiae (Group B), and S. dysgalactiae subsp equisimilis (Groups C and G); and γ-hemolytic, such as Enterococcus faecalis and E. faecium (Wessels, 2024). Streptococcal infections can be manifested in a variety of pathologies, including cutaneous infections, pharyngitis, acute rheumatic fever, pneumonia, postpartum endometritis, and toxic shock syndrome to name a few. Streptococcal infections can be identified using bacterial cultures obtained from blood, saliva, pus, mucosal, and skin samples as well as rapid antigen diagnostic testing (RADT) and nucleic acid-based methodologies (Chow, 2023; Wessels, 2024).
 
Regulatory Status
 
Lyra Direct Strep Assay (k133833) was approved by the U.S. Food and Drug Administration (FDA) on  April 16, 2014 and reclassified it on 07/11/2014. It is a “Real-Time PCR in vitro diagnostic test for the qualitative detection and differentiation of Group A β-hemolytic Streptococcus (Streptococcus pyogenes) and pyogenic Group C and G β-hemolytic Streptococcus nucleic acids isolated from throat swab specimens obtained from patients with signs and symptoms of pharyngitis, such as sore throat. The assay does not differentiate between pyogenic Groups C and G β-hemolytic streptococcus” (Hojvat, 2014). The FDA has also approved the Solana Strep Complete Assay by Quidel that is “an in vitro diagnostic test for the detection of Group A, C and G β-hemolytic streptococcus in throat swab specimens from symptomatic patients” on 10/25/2016 (K162274) (FDA, 2016).
 
GenePOC’s Strep A assay was approved by the U.S. Food and Drug Administration (FDA) on March 6, 2019 to be performed using GenePOC’s Revogene instrument as a “single-use test for qualitative detection of Streptococcus pyogenes (group A Streptococcus-GAS) nucleic acids from throat swab specimens obtained from patients with signs and symptoms of pharyngitis” (FDA, 2019).
 
Mesa Biotech, Inc.’s Accula Strep A Test was approved by the U.S. Food and Drug Administration (FDA) on November 9, 2020, which is a semi-automated, colorimetric polymerase chain reaction (PCR) nucleic acid amplification test “to qualitatively detect Streptococcus pyogenes (Group A β-hemolytic Streptococcus, Strep A) bacterial nucleic acid from unprocessed throat swabs that have not undergone prior nucleic acid extraction” (FDA, 2020).
 
Many labs have developed specific tests that they must validate and perform in house. These laboratory-developed tests (LDTs) are regulated by the Centers for Medicare and Medicaid (CMS) as high-complexity tests under the Clinical Laboratory Improvement Amendments of 1988 (CLIA ’88). LDTs are not approved or cleared by the U. S. Food and Drug Administration; however, FDA clearance or approval is not currently required for clinical use.
 
Coding
 
See CPT/HCPCS Code section below.
Policy/
Coverage:
This policy applies to health plans that utilize a routine laboratory management vendor, which include Arkansas Blue Cross and Blue Shield, Federal Employee Health Benefit Plan and Postal Service Health Benefit Plan, Health Advantage, and Octave Blue Cross and Blue Shield fully insured plans, including the Metallic and ARHOME plans and Complete/Complete Plus plans.  Additionally, this policy will apply to the Farm Bureau and Level Funded plans.
 
Effective February 1, 2025
 
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
β-Hemolytic streptococcal testing meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes for any of the following indications:
 
    1. Bacterial culture testing from a throat swab for the detection of a streptococcal infection causing respiratory illness, when ONE of the following conditions is met:
a. When the individual has a modified Centor criteria score of 3 or greater (Centor criteria includes tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough with each criterion being worth one point (Chow, 2023));
b. When the individual is suspected of having bacterial pharyngitis in the absence of viral features, (e.g., cough, oral ulcers, rhinorrhea);
c. Following a negative rapid antigen diagnostic test (RADT) in a symptomatic child or adolescent.
2. Blood culture testing for streptococcal infection when one of the following conditions is met:
a. For individuals who fail to demonstrate clinical improvement;
b. For individuals who have progressive symptoms or clinical deterioration after the initiation of antibiotic therapy;
c. In cases of suspected prosthetic joint infection.
3. In cases of skin and/or soft tissue infections, bacterial culture testing for streptococcal infection from a skin swab or from pus.
4. For individuals with suspected acute rheumatic fever (ARF) or post-streptococcal glomerulonephritis (PSGN), the following testing is covered:
a. Serological titer testing;
b. Anti-streptolysin O immunoassay;
c. Hyaluronidase activity or anti-hyaluronidase immunoassay;
d. Streptokinase activity or anti-streptokinase immunoassay.
 
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
 
β-Hemolytic streptococcal testing for any indication or circumstance not described above, does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, β-hemolytic streptococcal testing for any indication or circumstance not described above is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Bacterial culture testing for streptococci from a throat swab in cases of suspected viral pharyngitis does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
 
For members with contracts without primary coverage criteria, bacterial culture testing for streptococci from a throat swab in cases of suspected viral pharyngitis is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Except in cases of asymptomatic children under the age of three years who have a mitigating circumstance (including a symptomatic family member), RADT for a streptococcal infection does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes in any of the following situations:
 
      1. As a follow-up test for individuals who have had either a bacterial culture test or a nucleic acid test for a streptococcal infection.
      2. As a screening method in an asymptomatic patient.
      3. For individuals with suspected viral pharyngitis.
 
For members with contracts without primary coverage criteria, except in cases of asymptomatic children under the age of three years who have a mitigating circumstance (including a symptomatic family member), RADT for a streptococcal infection is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
For all situations not described above, serological titer testing does not meet primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and is not covered.
 
For members with contracts without primary coverage criteria, for all situations not described above, serological titer testing is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
Simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter does not meet primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and is not covered.
 
For members with contracts without primary coverage criteria, simultaneous ordering of both direct probe and amplification probe for the same organism in a single encounter is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
For all situations not described above, testing with an anti-streptolysin O immunoassay, a hyaluronidase activity or anti-hyaluronidase immunoassay, or a streptokinase activity or anti-streptokinase immunoassay does not meet primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and is not covered.
 
For members with contracts without primary coverage criteria, for all situations not described above, testing with an anti-streptolysin O immunoassay, a hyaluronidase activity or anti-hyaluronidase immunoassay, or a streptokinase activity or anti-streptokinase immunoassay is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
 
For all situations, the following tests do not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes and are not covered:
 
      1. Panel tests that screen and identify multiple streptococcal strains (S. pyogenes [group A], S. agalactiae [group B], S. dysgalactiae [groups C/G], alpha-hemolytic streptococcus, and/or gamma-hemolytic streptococcus), using either immunoassay or nucleic acid-based assays (e.g., Solana Strep Complete Assay, Lyra Direct Strep Assay);
      2. MALDI-TOF identification of streptococcus;
      3. The quantification of any strain of streptococcus using nucleic acid amplification, including PCR;
      4. Nicotinamide-adenine dinucleotidase activity or anti-nicotinamide-adenine immunoassay.
 
For members with contracts without primary coverage criteria, the situations above are considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Rationale:
Bacterial acute pharyngitis is caused most often by a Group A Streptococcus (S. pyogenes or GAS), accounting for 5-15% of all acute pharyngitis cases in adults. Group C or Group G Streptococcus (S. dysgalactiae subsp equisimilis or GCS/GGS) is believed to be a causative agent in 5-10% of the cases of pharyngitis; however, “pharyngitis cause group C or G Streptococcus is clinically indistinguishable from GAS pharyngitis” but is more common in young adults and college students (Chow, 2023). “Diagnosis of infection due to group C streptococci (GCS) and group G streptococci (GGS) depends on identification of the organism in a culture from a clinical specimen. In general, a positive culture from a normally sterile site, such as blood, synovial fluid, or cerebrospinal fluid (CSF), can be considered definitive evidence of infection in the setting of a compatible clinical syndrome. The interpretation of positive cultures for GCS or GGS from the pharynx or from cutaneous sites such as open ulcers or wounds is less straightforward since asymptomatic colonization of the upper airway and skin also occurs” (Wessels, 2024). GAS occurs most frequently in the very young and the elderly; although, GAS infections can occur in any age-group. The rates pf severe GAS infections have been increasing in the United States as well as in other developed nations (Schwartz, 1990).
 
The Centor criteria can be used to gauge the likelihood of pharyngitis due to a GAS infection. The four components of the Centor criteria are tonsillar exudates, tender anterior cervical lymphadenopathy, fever, and absence of cough with each criterion being worth one point. Patients who score less than three according to the Centor criteria are unlikely to have pharyngitis due to GAS and do not require strep testing or antibiotics; patients scoring ≥ three can be tested for GAS pharyngitis (Chow, 2023).
 
Group A Streptococcus is associated with bacterial pharyngitis, scarlet fever, acute rheumatic fever, and post-streptococcal glomerulonephritis. Group A strep pharyngitis presents as a sudden onset of sore throat with odynophagia and fever; it is commonly referred to as “strep throat.” In children, additional symptoms can include abdominal pain, nausea, and vomiting. Viral pharyngitis, which accounts for more than 80% of pharyngitis, typically presents with cough, rhinorrhea, hoarseness, oral ulcers, and conjunctivitis unlike GAS pharyngitis. Rare cases of mucopurulent rhinitis caused by GAS have been reported in children under the age of three (CDC, 2024a). Scarlet fever can accompany strep throat. Besides the typical erythematous rash that typically begins on the trunk before spreading outward, scarlet fever can also present as a flushed face, “and the area around the mouth may appear pale (i.e., circumoral pallor).” “Strawberry tongue” can occur due to “yellowish white coating with red papillae” (CDC, 2024b). Scarlet fever is more easily transmitted from asymptomatic carriers through saliva and nasal secretions. Acute Rheumatic Fever (AFR), besides the characteristic fever, can affect the cardiovascular system (carditis and valvulitis), the musculoskeletal system (arthritis), the integumentary system (subcutaneous nodules and erythema marginatum), and the central nervous system (chorea). “Inadequate or lack of antibiotic treatment of streptococcal pharyngitis increases the risk of someone developing acute rheumatic fever. In approximately one-third of patients, acute rheumatic fever follows subclinical streptococcal infections or infections for which medical attention was not sought” (CDC, 2024d). Post-streptococcal glomerulonephritis (PSGN) presents with edema, hypertension, proteinuria, macroscopic hematuria, lethargy, and, at times, anorexia. “Laboratory examination usually reveals mild normocytic normochromic anemia, slight hypoproteinemia, elevated blood urea nitrogen and creatinine, elevated erythrocyte sedimentation rate, and low total hemolytic complement and C3 complement.” Urine output is usually decreased, and urine examination “often reveals protein (usually less than 3 grams per day) and hemoglobin with red blood cell casts” (CDC, 2024c).
 
The virulence factors of GAS include M proteins, a group of more than 80 known proteins that protein the bacteria against phagocytosis; streptolysin O, a thiol-activated cytolysin; hyaluronidase, which hydrolyzes hyaluronic acid within the host tissue; streptokinase, an enzyme that activates plasmin; nicotinamide-adenine dinucleotidase (NADase), a glycohydrolase of uncertain function; and deoxyribonucleases (DNases) A, B, C, and D. Streptolysin O binds to the eukaryotic membrane’s cholesterol to facilitate the characteristic cellular lysis of a GAS infection. Cholesterol and anti-streptolysis O (ASO) antibodies can mitigate streptolysin O damage, and ASO titers often increase following an infection with the peak occurring around four to five weeks post-infection. “Nonsuppurative complications such as rheumatic fever and poststreptococcal glomerulonephritis generally develop during the second or third week of illness. About 80 percent of patients with acute rheumatic fever or poststreptococcal glomerulonephritis demonstrate a rise in ASO titer; however, the degree of ASO titer elevation does not correlate with severity of disease. In patients with suspected rheumatic fever or glomerulonephritis but with an undetectable ASO titer, prompt testing for other antistreptococcal antibodies such as anti-DNase B (detectable for six to nine months following infection), streptokinase, and antihyaluronidase should be performed” (Stevens, 2024).
 
Acute rheumatic fever (ARF) can occur two to four weeks following GAS pharyngitis. The five major manifestations of ARF are carditis and valvulitis (up to 70% of patients exhibit this condition with ARF), arthritis (up to 66%), CNS system involvement (10-30%), subcutaneous nodules (0-10%), and erythema marginatum (less than 6%) (Steer, 2024).  A diagnosis of ARF is not predicated by confirmation of a preceding GAS infection; however, it is helpful, especially in diagnosing children and young adults with arthritis and/or carditis. Evidence of GAS should include either a positive throat culture, a positive RADT, or an elevated or rising titer of either ASO or anti-DNase B. These two antibodies are used frequently in clinical practice due to their high sensitivity in diagnosing streptococcal infections (Steer, 2024; Steer,2015).
A study by Blyth and Robertson demonstrated that the sensitivity of using only a single antibody in the diagnosis of streptococcus ranged from 70.5-72.7%; however, the combination of ASO and anti-DNase B increased the specificity to 88.6% with a sensitivity of 95.5%. The addition of anti-streptokinase (ASK) did not increase either the sensitivity or specificity of testing (Blyth, 2006).
 
A study in Norway in 2013 showed that necrotizing soft tissue infections can be caused by GAS or GGS/GCS. The mean annual incidence rate is 1.4 per 100,000. During the time period studied (2000-2009), 61 cases of necrotizing soft tissue infections in Norway were due to GAS while nine cases were due to GCS/GGS. “Our findings indicate a high frequency of streptococcal necrotizing fasciitis in our community. GCS/GGS infections contribute to the disease burden but differ from GAS cases in frequency and predisposing factors.” They note that “the GCS/GGS patients were older, had comorbidities more often and had anatomically more superficial disease than the GAS patients” (Bruun, 2013). A review in 2014 also noted the population most affected by GCS/GGS, but they note that “the case fatality in bacteremia has been reported to be 15-18%” (Rantala, 2014).
 
Group B Streptococcus (GBS) is frequently found in human gastrointestinal tracts and genitalia and can be spread to the upper respiratory tract of newborns. In neonates, GBS infections can cause bacteremia, pneumonia, meningitis, and sepsis. GBS can also cause complications in pregnancy, such as urinary tract infections and chorioamnionitis. GBS, in pregnant and postpartum individuals, is of special concern since it is implicated in up to 31% of cases of bacteremia without a focus, eight percent of postpartum endometritis, and two percent of pneumonia; moreover, if left unchecked, GBS can also result in preterm labor and miscarriage. In the adult population at large, GBS infections can be manifest as soft tissue infections, sepsis, and bacteremia (Barshak, 2024; Puopolo, 2024). “Invasive disease in infants is categorized on the basis of chronologic age at onset. Early-onset disease usually occurs within the first 24 hours of life (range, 0 through 6 days) and is characterized by signs of systemic infection, respiratory distress, apnea, shock, pneumonia, and less often, meningitis (5%–10% of cases). Late-onset disease, which typically occurs at 3 to 4 weeks of age (range, 7 through 89 days), commonly manifests as occult bacteremia or meningitis (approximately 30% of cases); other focal infections, such as osteomyelitis, septic arthritis, necrotizing fasciitis, pneumonia, adenitis, and cellulitis, occur less commonly. Nearly 50% of survivors of early- or late-onset meningitis have long-term neurologic sequelae (encephalomalacia, cortical blindness, cerebral palsy, visual impairment, hearing deficits, or learning disabilities). Late, late-onset disease occurs at 90 days of age and beyond, usually in very preterm infants requiring prolonged hospitalization” (Pediatrics, 2018).
 
Clinical Utility and Validity
Rapid in vitro diagnostic tests (RIDT), such as the Alere I Strep A, have been CLIA-waived by the FDA. These tests provide results more quickly than the traditional “gold standard” bacterial culture testing. A 2018 study comparing rapid antigen GAS testing, the Alere I Strep A test—an RIDT using isothermal nucleic acid amplification, and throat cultures. “The sensitivity and specificity of the molecular test were 98% and 100%, respectively, compared with culture. There was a 9% false-positive rate with the rapid antigen-based testing. The Alere test is sufficiently sensitive and specific for definitive GAS testing in a pediatric urgent care setting” (Weinzierl, 2018). Cohen et al extensively reviewed the use of rapid antigen detection tests (RADT) for GAS in children (Cohen, 2019). They reviewed 98 unique studies consisting of a total of 101,121 participants and compared both major types of RADTs-enzyme immunoassays (EIA) and optical immunoassays (OIA). “RADT had a summary sensitivity of 85.6%. There was substantial heterogeneity in sensitivity across studies; specificity was more stable. There was no trade-off between sensitivity and specificity. The sensitivity of EIA and OIA tests was comparable (summary sensitivity 85.4% versus 86.2%). Based on these results, we would expect that amongst 100 children with strep throat, 86 would be correctly detected with the rapid test while 14 would be missed and not receive antibiotic treatment” (Cohen, 2016). Another multicenter study using the Alere I Strep A test on cultures obtained from 481 patients of all ages show that the RIDT had 96.0% sensitivity and 94.6% specificity. The authors conclude that this “could provide a one-step, rapid, point-of-care testing method for GAS pharyngitis and obviate backup testing on negative results” (Cohen, 2015). This study did note that there are newer tests available that have higher sensitivity, but these tests require more time than the Alere I strep A method.
 
Due to the time constraints of clinical laboratories and the variability of RADTs, nucleic acid amplification test (NAAT) use has been increasing in clinical settings. The FDA has approved multiple NAATs  (3 min 16 s versus 1 min 40 s per specimen) for the detection of Streptococcus. The Lyra Direct strep assay is an FDA-approved, NAAT that uses real-time PCR to qualitatively detect the presence of GAS and GGS/GCS in throat swab samples. It should be noted, though, that this assay does not distinguish between GGS and GCS. A study by Boyanton et al evaluated the efficacy of the Lyra Direct method as compared to the traditional, time-consuming culture test for GAS and GGS/GCS. The sample sizes were not large (n = 19 for GAS and n = 5 for GGS/GCS out of a total of 161 samples submitted); however, the Lyra Direct strep assay did correctly detect “all β -hemolytic streptococci.” and “in batch mode, the Lyra assay reduced intra-laboratory turnaround time by 60% (18.1 h versus 45.0 h) but increased hands-on time by 96% (Boyanton, 2016). The Solana method is also as FDA-approved NAAT, but it uses a rapid helicase-dependent amplification (HDA) methodology. Solana is available for either GAS testing or as a panel testing for either GAS, GCS, or GGS. A study by Uphoff et al compared the Solana GAS testing to that of conventional culture testing (Uphoff, 2016). Their research used 1082 throat swab specimens.  The traditional culture tested positive in 20.7% of the samples as compared to 22.6% positive values in the HDA-based methodology. The Solana assay in their results had 98.2% sensitivity and 97.2% specificity. “In 35 min, the HDA method provided rapid, sensitive GAS detection, making culture confirmation unnecessary” (Uphoff, 2016). Recently another study compared an HDA-based method to the Simplex GAS Direct PCR-based method, which is another FDA-approved diagnostic test. The Simplex GAS Direct method does not require initial DNA extraction from the sample, a potential time-saving benefit. The study used 289 throat swabs. The HDA based method “compared to Simplexa qPCR had sensitivity, specificity, positive predictive value and negative predictive value of 93.1% vs 100%, 100% vs 100%, 100% vs 100% and 98.31% vs 100% respectively. Simplexa qPCR has improved performance and diagnostic efficiency in a high-volume laboratory compared to [HDA-based method] for GAS detection in throat swabs” (Church, 2018).
 
The Solana Strep Complete Assay by Quidel received FDA clearance in 2016. According to Quidel’s FDA application, it is defined as “a rapid in vitro diagnostic test, using isothermal amplification technology (helicase-dependent amplification, HDA) for the qualitative detection and differentiation of Streptococcus pyogenes (Group A β-hemolytic Streptococcus) and Streptococcus dysgalactiae (pyogenic Group C and G β -hemolytic Streptococcus) nucleic acids isolated from throat swab specimens obtained from patients with signs and symptoms of pharyngitis, such as sore throat” (Lollar, 2016). This test must be performed using Quidel’s Solana proprietary equipment. According to the 510(k) application, the Solana Strep Complete Assay panel has a clinical sensitivity and specificity for GAS of 98.8% and 98.9%, respectively, as compared to the Lyra Direct Strep Assay’s reported 96.5% sensitivity and 98.0% specificity for GAS. The Lyra Direct Strep Assay is a real-time PCR-based assay that cannot differentiate between the pyogenic strains of streptococci. Concerning the pyrogenic GCS/GGS, the Solana Strep Complete Assay panel has a clinical sensitivity of 100% with a specificity of 99.5% as compared to Lyra Direct Strep Assay’s reported 95.7% sensitivity and 98.3% specificity for GCS/GGS strains. The reported testing time also varies between the two assays with Solana requiring 25 minutes versus 60-70 minutes for the Lyra Direct Strep Assay (Lollar, 2016).
 
A recent study by Helmig and Gertsen evaluated the accuracy of PCR-based testing for GBS in pregnant individuals (Helmig, 2017). Their study used rectovaginal swabs from 106 women in gestational weeks 35-37. For each, both a GBC culture and a PCR-based molecular GBS test (Xpert GBS of Cepheid Ltd) were performed. Only one PCR test yielded no result, so the invalid PCR-based test rate is <1%. There were 25/106 of the GBS cultures tested positive as compared to 27/105 of the PCR-based test. The specificity of the PCR-based test was 97.5% with a 100% sensitivity and a 92.6% positive predictive value. The authors conclude that “the PCR test has sufficient accuracy to direct intrapartum antibiotic prophylaxis for GBS transmission during delivery” (Helmig, 2017). A preliminary study in France of 1416 mothers with newborns compared swab cultures and GBS PCR assay for their predictive value of early-onset bacterial sepsis (EOS) in newborns since GBS is the most common cause of EOS. The results show that “the diagnostic values of the [LR]: 0.3 [0.1-0.9] vs. 0.6 [0.4-1.1]). These results suggest that the intrapartum GBS PCR assay offers a better predictive value of GBS EOS than the usual vaginal culture swab at the 9th month but requires confirmation by large studies” (Raignoux, 2016).
 
Luo et al “evaluated the overall diagnosis and treatment of acute pharyngitis in the United States, including predictors of test type and antibiotic prescription.” Five categories of tests were identified, which were RADT [rapid antigen detection test], RADT plus culture, other tests, nucleic acid amplification testing (NAAT), and no test. Pharyngitis events from 2011-2015 were examined and a total of 18.8 million pharyngitis events across 11.6 million patients were included. Overall, 68.2% of events were found to occur once, with 29.1% requiring further follow-up. Furthermore, 43% of events were diagnosed by RADT and 20% were diagnosed by RADT plus culture. NAAT testing also increased 3.5-fold from 2011-2015 (going from 0.06% to 0.27%). Antibiotics were used in 49.3% of events as a whole. For RADT plus culture, antibiotics were used 31.2% of the time, for NAAT alone, 34.5%, for RADT alone, 54.2%, for no test, 57.1%. The authors concluded that “Diagnostic testing can help lower the incidence of inappropriate antibiotic use, and inclusion of NAAT in the clinical guidelines for GAS pharyngitis warrants consideration” (Luo, 2019).
 
O. Luiz et al evaluated the “prevalence and persistence of β -hemolytic streptococci throat carriage and type the bacterial population.” A total of 121 children and 127 young adult volunteers contributed throat swabs (for culture), and these volunteers were screened quarterly for β -hemolytic bacterial species. Carriage was detected in 34 volunteers (13.7%). Seventeen children were found to carry Group A Streptococcus, while seventeen young adults were found to carry four separate subspecies (Streptococcus dysgalactiae subsp. equisimilis (SDSE), Streptococcus pyogenes, Streptococcus agalactiae and the Streptococcus anginosus group). The authors also identified persistent carriage for as long as six months in two children and for as long as one year in three young adults. The authors concluded that “prevalence was slightly greater among children, but persistent carriage was greater among young adults, with SDSE being the species most associated with persistence” (Luiz, 2019).
 
Fraser et al performed a meta-analysis to assess the cost-effectiveness of point-of-care testing for detection of Group A Streptococcus. The authors remarked that this type of testing has seen increased use as an adjunct for managing care, such as for prescribing antibiotics. Thirty-eight studies of clinical effectiveness were included, along with three studies of cost-effectiveness. Twenty-six articles “reported on the test accuracy of point-of-care tests and/or clinical scores with biological culture as a reference standard.” Overall, 21 point-of-care tests were evaluated. The authors identified two populations of interest; “patients with Centor/McIsaac scores of ≥ 3 points or FeverPAIN scores of ≥ 4 points.” Test sensitivity for these populations ranged from 0.829-0.946 while test specificity ranged from 0.849-0.991. However, the authors did note there was significant heterogeneity and expressed doubts that any single study “accurately captured a test's true performance.” The authors developed an economic model to explore the cost-effectiveness of this type of testing, and 14 of the 21 tests were included in this model. Per the current National Institute for Health and Care Excellence's cost-effectiveness thresholds, these tests were not found to be cost-effective. The authors acknowledged significant uncertainties in the estimates, such as penalties for antibiotic over-prescriptions. The authors concluded that “the systematic review and the cost-effectiveness models identified uncertainties around the adoption of point-of-care tests in primary and secondary care settings. Although sensitivity and specificity estimates are promising, we have little information to establish the most accurate point-of-care tests in primary and secondary care settings. Although sensitivity and specificity estimates are promising, we have little information to establish the most accurate point-of-care test” (Fraser, 2020; Kim, 2019)
 
Bilir et al studied the cost-effectiveness of point of care (POC) nucleic acid amplification tests (NAAT) for streptococcus in the US. Point of care NAAT was compared to rapid antigen detection tests (RADT) and culture. Costs, clinical effects, antibiotic complications, number of patients treated, and antibiotic utilization were studied. Analysis showed that the POC NAAT method would cost $44 per patient while RADT and culture would cost $78 per patient. "Compared with RADT + culture, POC NAAT would increase the number of appropriately treated patients and avert unnecessary use of antibiotics.” According to the results, “POC NAAT would be less costly and more effective than RADT + culture; POC NAAT adoption may yield cost savings to US third-party payers. Access to POC NAAT is important to optimize GAS diagnosis and treatment decisions in the United States" (Bilir, 2021).
 
In a metanalysis, Dubois et al studied the diagnostic accuracy of rapid antigen detection tests (NADTs) vs rapid nucleic acid tests (RNATs) for diagnosis of group A streptococcal pharyngitis. A total of 38 studies using RNAT were included, with a sensitivity of 97.5% and specificity of 95.1%. RADTs had a sensitivity of 82.3%, but specificity was similar to the sensitivity of RNATs. Overall, RNATs were more sensitive than RADTs. The authors conclude that "the high diagnostic accuracy of RNATs may allow their use as stand-alone tests to diagnose group A streptococcus pharyngitis" (Dubois, 2021).
 
McCarty et al studied the clinical utility on the GenMark Dx ePlex® blood culture identification gram-positive panel. The panel results were evaluated and compared to MALDI-TOF mass spectrometry and traditional antimicrobial susceptibility testing. One hundred Gram-Positive bacteria were represented. “The positive percent agreement (PPA) was 97/97 with 2 false positives.” The study included chart reviews of 80 patients. The average time for organism identification was 24.4 hours faster, and the average time for optimization was 29.2 hours faster for the eight patients identified with organisms such as streptococci. The authors “confirm high sensitivity and specificity of the FDA-cleared GenMark Dx ePlex BCID-GP Panel” compared to MALDI-TOF MS on bacterial isolates and identify opportunities for earlier optimization of antimicrobial therapy that may also be accompanied by potential cost savings (McCarty, 2022).
 
Guidelines and Recommendations
 
Centers for Disease Control and Prevention
Acute Pharyngitis (CDC, 2024a): Most cases of acute pharyngitis are viral. Only 20-30% of pharyngitis episodes in children and 5-15% in adults are due to group A Streptococcus (GAS). History and clinical examination can be used to diagnosis viral pharyngitis when clear viral symptoms (e.g., cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis) are present; these patients do not need testing for group A strep. However, clinical examination cannot be used to differentiate viral and group A strep pharyngitis in the absence of viral symptoms, even for experienced clinicians. The diagnosis of group A strep pharyngitis is confirmed by either a rapid antigen detection test (RADT) or a throat culture. RADTs have high specificity for group A strep but varying sensitivities when compared to throat culture, which is considered the gold standard diagnostic test. Healthcare providers can use a positive RADT or throat culture as confirmation of group A strep pharyngitis. For children older than three years old healthcare providers should follow up a negative RADT with a throat culture. For all other ages a throat culture after a negative RADT is not routinely indicated (CDC, 2024a).
 
Scarlet Fever (CDC, 2024b): Scarlet fever (scarlatina) consists of an erythematous rash caused by GAS and can occur along with acute pharyngitis. “The differential diagnosis of scarlet fever with pharyngitis includes multiple viral pathogens that can cause acute pharyngitis with a viral exanthema.” To confirm scarlet fever with pharyngitis, healthcare providers need to use either a rapid antigen detection test (RADT) or throat culture. RADTs have high specificity for group A strep but varying sensitivities when compared to throat culture. Throat culture is the gold standard diagnostic test. Clinicians should follow up a negative RADT in children older than three with symptoms of scarlet fever with a throat culture. Clinicians should have a mechanism in place to contact the family and initiate antibiotics if the back-up throat culture is positive (CDC, 2024b).
 
Post-Streptococcal Glomerulonephritis (PSGN) (CDC, 2024c): PSGN is primarily due to a GAS infection, but rare cases of GCS-induced PSGN have been reported. Clinical features include edema, hypertension, proteinuria, macroscopic hematuria, and lethargy. As such, “The differential diagnosis of PSGN includes other infectious and non-infectious causes of acute glomerulonephritis. Clinical history and findings with evidence of a preceding group A strep infection should inform a PSGN diagnosis. Evidence of preceding group A strep infection can include
 
    • Isolation of group A strep from the throat
    • Isolation of group A strep from skin lesions
    • Elevated streptococcal antibodies” (CDC, 2024c).
 
Acute Rheumatic Fever (CDC, 2024d): “The differential diagnosis of acute rheumatic fever is broad due to the various symptoms of the disease. The differential diagnosis may include specific autoimmune diseases, inflammatory diseases, cancers, and other conditions.” The CDC notes that no definitive diagnostic test exists for acute rheumatic fever and recommends using the Jones criteria (endorsed by the American Heart Association) to make a clinical diagnosis, which now includes the addition of subclinical carditis as a major manifestation for low, moderate, and high-risk populations” (CDC, 2024d).
 
American Association of Pediatrics (AAP)
The AAP has published the Red Book as guidance for infectious diseases in the pediatric population (Kimberlin, 2021). Their relevant comments and recommendations include:
 
    • “Children with pharyngitis and obvious viral symptoms (e.g., rhinorrhea, cough, hoarseness, oral ulcers) should not be tested or treated for GAS [Group A Streptococcus] infection; testing also generally is not recommended for children younger than 3 years.”
    • “Several rapid diagnostic tests for GAS pharyngitis are available…Specificities of these tests generally are high (very few false-positive results), but the reported sensitivities vary considerably (i.e., false-negative results occur).”
    • “The US Food and Drug Administration (FDA) has cleared a variety of rapid tests for use in home settings. Parents should be informed that home use is discouraged because of the risk of false-positive testing that represents colonization.”
    • “Because of the very high specificity of rapid tests, a positive test result does not require throat culture confirmation. Rapid diagnostic tests using techniques such as polymerase chain reaction (PCR), chemiluminescent DNA probes, and isothermal nucleic acid amplification tests have been developed…Some studies suggest that these tests may be as sensitive as standard throat cultures on sheep blood agar.”
    • “Children with manifestations highly suggestive of viral infection, such as coryza, conjunctivitis, hoarseness, cough, anterior stomatitis, discrete ulcerative oral lesions, or diarrhea, are very unlikely to have true GAS pharyngitis and should not be tested.”
    • “Testing children younger than 3 years generally is not indicated. Although small outbreaks of GAS pharyngitis have been reported in young children in childcare settings, the risk of ARF is so remote in young children in industrialized countries that diagnostic studies for GAS pharyngitis generally are not indicated for children younger than 3 years.”
    • “In contrast, children with acute onset of sore throat and clinical signs and symptoms such as pharyngeal exudate, pain on swallowing, fever, and enlarged tender anterior cervical lymph nodes, without concurrent viral symptoms and/or exposure to a person with GAS pharyngitis, are more likely to have GAS infection and should have a rapid antigen test and a throat culture if the rapid test result is negative, with treatment initiated if a test result is positive.”
    • “Testing asymptomatic household contacts for GAS infection is not recommended except when the contacts are at increased risk of developing sequelae of GAS infection, such as ARF or acute glomerulonephritis; if test results are positive, such contacts should be treated.”
    • “Testing asymptomatic household contacts usually is not helpful. However, if multiple household members have pharyngitis or other GAS infections, simultaneous cultures of all household members and treatment of all with positive cultures or rapid antigen test results may be of value.”
    • “In suspected invasive GAS infections, cultures of blood and of focal sites of possible infection are indicated.”
    • “Laboratory evidence of antecedent GAS infection should be confirmed in all cases of suspected ARF [acute rheumatic fever], and evidence includes an increased or rising ASO or anti-DNAase B titer, or a positive rapid antigen or streptococcal throat culture. Because of the long latency between GAS infection and presentation with chorea, such laboratory evidence may be lacking in cases where chorea is the major criteria.”
    • “Post-treatment throat swab cultures are indicated only for patients who are at particularly high risk of ARF [acute rheumatic fever] (e.g., those living in an area with endemic infection).”
 
Regarding the management of infants at risk of group B streptococcal disease, a list of recommendations was provided. The relevant points are included below:
 
    • “Early-onset GBS infection is diagnosed by blood or CSF culture. Common laboratory tests such as the complete blood cell count and C-reactive protein do not perform well in predicting early-onset infection, particularly among well-appearing infants at lowest baseline risk of infection.”
    • “Evaluation for late-onset GBS disease should be based on clinical signs of illness in the infant. Diagnosis is based on the isolation of group B streptococci from blood, CSF, or other normally sterile sites. Late-onset GBS disease occurs among infants born to mothers who had positive GBS screen results as well as those who had negative screen results during pregnancy. Adequate IAP does not protect infants from late-onset GBS disease” (Puopolo, 2019).
 
American Heart Association (AHA)
The AHA published a revision to the Jones criteria for diagnosis of acute rheumatic fever in 2015. In it, they note the importance of identifying laboratory evidence of a group A streptococcal infection. The AHA lists three clinical features that can serve as evidence for a preceding Group A Streptococcus infection, which are as follows:
 
    • “Increased or rising anti-streptolysin O titer or other streptococcal antibodies (anti-DNASE B). A rise in titer is better evidence than a single titer result.”
    • “A positive throat culture for group A β-hemolytic streptococci.”  
    • “A positive rapid group A streptococcal carbohydrate antigen test in a child whose clinical presentation suggests a high pretest probability of streptococcal pharyngitis” (Gewitz, 2015).
 
Institute for Clinical Systems Improvement (ICSI)
In 2017, the ICSI updated their guidelines titled Diagnosis and treatment of respiratory illness in children and adults. They give the following consensus recommendation: “It is the consensus of the ICSI work group to NOT test for Group A Streptococcal (GAS) pharyngitis in patients with modified Centor criteria scores less than three or when viral features like rhinorrhea, cough, oral ulcers and/or hoarseness are present. Testing should generally be reserved for patients when there is a high suspicion for GAS and for whom there is intention to treat with antibiotics” (Short, 2017). The Centor criteria include age of patient, physical state of the tonsils and lymph nodes, temperature, and presence or absence of cough (Centor, 2024).
 
American Thoracic Society (ATS) and Infectious Diseases Society of America (IDSA)
The ATS and IDSA published a joint guideline on the diagnosis and treatment of community-acquired pneumonia in adults. The guideline notes that group A Streptococcus may be associated with influenza pneumonia. Their relevant recommendations are listed below:
    • “We recommend not obtaining sputum Gram stain and culture routinely in adults with CAP managed in the outpatient setting (strong recommendation, very low quality of evidence).”
    • “We recommend not obtaining blood cultures in adults with CAP managed in the outpatient setting (strong recommendation, very low quality of evidence)” (Metlay, 2019).
 
Infectious Diseases Society of America (IDSA)
The 2014 update of the IDSA’s guidelines concerning skin and soft tissue infections included a recommendation (strong; moderate-quality evidence) of “Gram stain and culture of the pus or exudates from skin lesions of impetigo and ecthyma are recommended to help identify whether Staphylococcus aureus and/or β -hemolytic Streptococcus is the cause, but treatment without these studies is reasonable in typical cases.” They make a similar recommendation in the cases of pus from carbuncles and abscesses as well as pyomyositis; however, they do not recommend (strong, moderate) a “Gram stain and culture of pus from inflamed epidermoid cysts.” As for erysipelas and cellulitis, “cultures of blood or cutaneious aspirates, biopsies, or swabs are not routinely recommended (strong, moderate) …cultures of blood are recommended (strong, moderate), and cultures and microscopic examination of cutaneious aspirates, biopsies, or swabs should be considered in patients with malignancy on chemotherapy, neutropenia, severe cell-mediated immunodeficiency, immersion injuries, and animal bites (weak, moderate)” (Stevens, 2014).
 
The IDSA and the American Society for Microbiology (ASM) published a guideline in 2018 titled “A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases.” This guideline includes items on the laboratory diagnosis of pharyngitis, which are as follows:
    • For Streptococcus pyogenes, direct NAAT, nucleic acid probe tests, or a rapid direct antigen test (followed by a culture or NAAT test if negative) may all be performed.
    • For groups C and G β -hemolytic streptococci, a NAAT may be performed, or a combination of throat culture and antigen tests on isolates for group C and G streptococci may be performed.
Other relevant comments include:
    • “A rapid antigen test for Streptococcus pyogenes may be performed at the point of care by healthcare personnel or transported to the laboratory for performance of the test…in pediatric patients, if the direct antigen test is negative, and if the direct antigen test is known to have a sensitivity of <80%, a second throat swab should be examined by a more sensitive direct NAAT or by culture as a means of arbitrating possible false-negative direct antigen test results…this secondary testing is not necessarily required in adults”
    • “Direct and amplified NAATs for Streptococcus pyogenes are more sensitive than direct antigen tests and, as a result, negative direct NAAT results do not have to be arbitrated by a secondary test.”
    • "Detection of group C and G β -hemolytic streptococci is accomplished by throat culture in those patients in whom there exists a concern for an etiologic role for these organisms. Only large colon types are identified, as tiny colonies demonstrating groups C and G antigens are in the Streptococcus anginosus (S. milleri) group” (Miller, 2018).
 
American Academy of Otolaryngology-Head and Neck Surgery Foundation
Although the focus of this guideline is the tonsillectomy procedure in children, there are some relevant comments. The Academy notes that “In practice, streptococcal carriage is strongly suggested by positive strep cultures or other strep tests when the child lacks signs or symptoms of acute pharyngitis.” (Mitchell, 2019) IDSA endorsed this guideline in February 2019 (IDSA, 2019a).
 
American Academy of Orthopaedic Surgeons
Although this guideline focuses on management of periprosthetic joint infections, there is a relevant recommendation, which states that “synovial fluid aerobic and anaerobic bacterial cultures” have moderate evidence to support their use to “aid in the diagnosis of prosthetic joint infection (PJI)” (AAOS, 2019). IDSA endorsed this guideline in March 2019 (IDSA, 2019b).
 
2011 Pediatric Infectious Diseases Society (PIDS) and Infectious Diseases Society of America (IDSA)
The 2011 joint PIDS-IDSA guidelines concerning pediatric community-acquired pneumonia (CAP) recommended (strong recommendation; moderate-quality evidence) that “blood cultures should not be routinely performed in nontoxic, fully immunized children with CAP managed in the outpatient setting” and that “blood cultures should be obtained in children who fail to demonstrate clinical improvement and in those who have progressive symptoms or clinical deterioration after initiation of antibiotic therapy.” Concerning inpatient services, they recommend (strong recommendation; low-quality evidence) that “blood cultures should be obtained in children requiring hospitalization for presumed bacterial CAP that is moderate to severe, particularly those with complicated pneumonia”; however, “in improving patients who otherwise meet criteria for discharge, a positive blood culture with identification or susceptibility results pending should not be routinely preclude discharge of that patient with appropriate oral or intravenous. aureus, regardless of clinical status (strong recommendation; low-quality evidence).” With respect to sputum gram stain and culture, “sputum samples for culture and Gram stain should be obtained in hospitalized children who can produce sputum” (weak recommendation; low-quality evidence). They do not recommend using urinary antigen detection testing “for the diagnosis of pneumococcal pneumonia in children; false-positive tests are common (strong recommendation; high-quality evidence)” (Bradley, 2011).
 
American College of Obstetricians and Gynecologists (ACOG)
The ACOG issued Committee Opinion #797 in 2020. ACOG recommends that “Regardless of planned mode of birth, all pregnant women should undergo antepartum screening for GBS at 36 0/7–37 6/7 weeks of gestation, unless intrapartum antibiotic prophylaxis for GBS is indicated because of GBS bacteriuria during the pregnancy or because of a history of a previous GBS-infected newborn” (ACOG, 2020). This committee opinion was reaffirmed in 2022.
 
American Society for Microbiology
The ASM endorsed the above ACOG recommendation, stating that “The recommended screening interval has changed from 35-37 weeks (per CDC 2010 guidelines) to 36 0/7 to 37 6/7 weeks (ACOG 2019 recommendations).” Concerning identification of group B streptococcus, the ASM propounds the following:
 
“Recommendation: Acceptable phenotypic and proteomic methods of identification of candidate isolates include CAMP test, latex agglutination, and mass spectrometry.”
“Recommendation: Nucleic acid amplification-based identification of GBS from enrichment broth is acceptable, but not sufficient for all patients.”
 
“Recommendation: Latex agglutination directly from enrichment broth and direct-from-specimen immunoassays are unacceptable methods for GBS detection.”
 
The guideline also recommends performing “antimicrobial susceptibility testing on all GBS [Group B Streptococcus] isolates from pregnant women with penicillin allergy”, and most recently the ASM included options for vancomycin reporting (Filkins, 2021).
 
National Institute for Health and Care Excellence
The NICE published an update on “rapid tests for group A streptococcal infections in people with a sore throat.” They stated that “Rapid tests for strep A infections are not recommended for routine adoption for people with a sore throat. This is because their effect on improving antimicrobial prescribing and stewardship, and on patient outcomes, as compared with clinical scoring tools alone, is likely to be limited” (NICE, 2019).
CPT/HCPCS:
86060Antistreptolysin 0; titer
86063Antistreptolysin 0; screen
86215Deoxyribonuclease, antibody
86317Immunoassay for infectious agent antibody, quantitative, not otherwise specified
86318Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single-step method (eg, reagent strip);
86581Streptococcus pneumoniae antibody (IgG), serotypes, multiplex immunoassay, quantitative
87040Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate)
87070Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
87071Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool
87077Culture, bacterial; aerobic isolate, additional methods required for definitive identification, each isolate
87081Culture, presumptive, pathogenic organisms, screening only;
87430Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; Streptococcus, group A
87650Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, direct probe technique
87651Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, amplified probe technique
87652Infectious agent detection by nucleic acid (DNA or RNA); Streptococcus, group A, quantification
87797Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; direct probe technique, each organism
87798Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; amplified probe technique, each organism
87799Infectious agent detection by nucleic acid (DNA or RNA), not otherwise specified; quantification, each organism
87880Infectious agent antigen detection by immunoassay with direct optical (ie, visual) observation; Streptococcus, group A
References: AACC(2021) Strep Throat Test Association for Clinical Chemistry.Retrieved 08/03/2018 from https://labtestsonline.org/tests/strep-throat-test

AAOS(2019) DIAGNOSIS AND PREVENTION OF PERIPROSTHETIC JOINT INFECTIONS CLINICAL PRACTICE GUIDELINE https://aaos.org/globalassets/quality-and-practice-resources/pji/pji-clinical-practice-guideline-final-9-18-19-.pdf

ACOG(2020) Prevention of Group B Streptococcal Early-Onset Disease in Newborns https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/02/prevention-of-group-b-streptococcal-early-onset-disease-in-newborns

Barshak, MB(2022) Group B streptococcal infections in nonpregnant adults. Wolters Kluwer https://www.uptodate.com/contents/group-b-streptococcal-infections-in-nonpregnant-adults

Bilir, SP., Kruger, E., Faller, M., Munakata, J., Karichu, JK., Sickler, J., Cheng, MM(2021) US cost-effectiveness and budget impact of point-of-care NAAT for streptococcus Am J Manag Care, 27(5), e157-e163. https://doi.org/10.37765/ajmc.2021.88638

Blyth, CC., Robertson, P. W.(2006) Anti-streptococcal antibodies in the diagnosis of acute and post-streptococcal disease: streptokinase versus streptolysin O and deoxyribonuclease B. Pathology, 38(2), 152-156. https://doi.org/10.1080/00313020600557060

Boyanton, BL., Jr., Darnell, E.M., Prada, AE., Hansz, DM., Robinson-Dunn, B(2016) Evaluation of the Lyra Direct Strep Assay To Detect Group A Streptococcus and Group C and G Beta-Hemolytic Streptococcus from Pharyngeal Specimens. J Clin Microbiol, 54(1), 175-177. https://doi.org/10.1128/jcm.02405-15

Bradley, JS., Byington, CL., Shah, SS., Alverson, B., Carter, ER., Harrison, C., Kaplan, SL., Mace, SE., McCracken, JGH., Moore, MR., St Peter, SD., Stockwell, JA., Swanson, JT(2011) 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. Clinical Infectious Diseases, 53(7), e25-e76. https://doi.org/10.1093/cid/cir531

Bruun,T., Kittang, BR., de Hoog, BJ., Aardal, S., Flaatten, HK., Langeland, N., Mylvaganam, H., Vindenes, HA., Skrede, S(2013) Necrotizing soft tissue infections caused by Streptococcus pyogenes and Streptococcus dysgalactiae subsp. Equisimilis of groups C and G in western Norway. Clin Microbiol Infect, 19(12), E545-550. https://doi.org/10.1111/1469-0691.12276

CDC(2022) Acute Rheumatic Fever Centers for Disease Control and Prevention. Retrieved 8/10/2022 from https://www.cdc.gov/groupastrep/diseases-hcp/acute-rheumatic-fever.html

CDC(2022) Pharyngitis (Strep Throat) Centers for Disease Control and Prevention. Retrieved 8/10/2022 from https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

CDC(2022) Post-Streptococcal Glomerulonephritis Centers for Disease Control and Prevention. Retrieved 8/15/2022 from https://www.cdc.gov/groupastrep/diseases-hcp/post-streptococcal.html

CDC(2022) Scarlet Fever Centers for Disease Control and Prevention. Retrieved 8/10/2022 from https://www.cdc.gov/groupastrep/diseases-hcp/scarlet-fever.html

Centor, RM., McIsaac, W.(2022) Centor Score (Modified/McIsaac) for Strep Pharyngitis MDCalc. https://www.mdcalc.com/centor-score-modified-mcisaac-strep-pharyngitis

Chow, AW(2023) Evaluation of acute pharyngitis in adults https://www.uptodate.com/contents/evaluation-of-acute-pharyngitis-in-adults

Church, DL., Lloyd, T., Larios, O., Gregson, DB.(2018) Eval of Simplexa Group A Strep Direct Kit Compared to Hologic Group A Streptococcal Direct Assay for Detection of Group A Streptococcus in Throat Swabs J Clin Microbiol, 56(3). https://doi.org/10.1128/jcm.01666-17

Cohen, DM., Russo, ME., Jaggi, P., Kline, J., Gluckman, W., Parekh, A.(2015) Multicenter Clinical Evaluation of the Novel Alere i Strep A Isothermal Nucleic Acid Amplification Test J Clin Microbiol, 53(7), 2258-2261. https://doi.org/10.1128/jcm.00490-15

Cohen, JF., Bertille, N., Cohen, R., Chalumeau, M.(2016) Rapid antigen detection test for group A streptococcus in children with pharyngitis Cochrane Database Syst Rev, 7, Cd010502. https://doi.org/10.1002/14651858.CD010502.pub2

Dubois C, Smeesters PR, Refes Y, Levy C, Bidet P, Cohen R, Chalumeau M, Toubiana J, Cohen JF(2021) Diagnostic accuracy of rapid nucleic acid tests for group A streptococcal pharyngitis: systematic review and meta-analysis Clinical Microbiology and Infection. https://doi.org/10.1016/j.cmi.2021.04.021

FDA(2016) Product Classification U.S. Department of Health & Human Services. Retrieved 06/22/2018 from https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpcd/classification.cfm?ID=3515

FDA(2019) 510(k) Substantial Equivalence Determination Decision Summary (K183366) https://www.accessdata.fda.gov/cdrh_docs/reviews/K183366.pdf

FDA(2020) Groups A, C And G Beta-Hemolytic Streptococcus Nucleic Acid Amplification System https://www.accessdata.fda.gov/scripts/cdrh/devicesatfda/index.cfm?db=pmn&id=K201269

Filkins L, Hauser J, Robinson-Dunn B, Tibbetts R, Boyanton B, Revell P(2021) Guidelines for the Detection and Identification of Group B Streptococcus https://asm.org/Guideline/Guidelines-for-the-Detection-and-Identification-of

Fraser H, Gallacher D, Achana F, Court R, Taylor-Phillips S, Nduka C, Stinton C, Willans R, Gill P, Mistry H(2020) Rapid antigen detection and molecular tests for group A streptococcal infections for acute sore throat: systematic reviews and economic evaluation Health Technol Assess, 24(31), 1-232. https://doi.org/10.3310/hta24310

Freeman J, Roberts S(2023) Approach to Gram stain and culture results in the microbiology laboratory. Wolters Kluwer https://www.uptodate.com/contents/approach-to-gram-stain-and-culture-results-in-the-microbiology-laboratory

Gera K, McIver KS(2013) Laboratory Growth and Maintenance of Streptococcus pyogenes (The Group A Streptococcus, GAS) Curr Protoc Microbiol, 30, 9d.2.1-9d.2.13. https://doi.org/10.1002/9780471729259.mc09d02s30

Gewitz MH, Baltimore RS, Tani LY, Sable CA, Shulman ST, Carapetis J, Remenyi B, Taubert KA, Bolger AF, Beerman L, Mayosi BM, Beaton A, Pandian NG, Kaplan EL(2015) Revision of the Jones Criteria for the Diagnosis of Acute Rheumatic Fever in the Era of Doppler Echocardiography. Circulation, 131(20), 1806-1818. https://doi.org/10.1161/CIR.0000000000000205

Helmig RB, Gertsen JB(2017) Diagnostic accuracy of polymerase chain reaction for intrapartum detection of group B streptococcus colonization Acta Obstet Gynecol Scand, 96(9), 1070-1074. https://doi.org/10.1111/aogs.13169

Hojvat SA(2014) Evaluation of Class III Designation--De Novo Request. Silver Spring, MD: Food and Drug Administration Retrieved from https://www.accessdata.fda.gov/cdrh_docs/pdf13/k133883.pdf

IDSA(2019) Clinical Practice Guideline: Tonsillectomy in Children (Update) (Endorsed) https://www.idsociety.org/practice-guideline/tonsillectomy-in-children/

IDSA(2019) Diagnosis and Prevention of Periprosthetic Joint Infections (Endorsed) https://www.idsociety.org/practice-guideline/periprosthetic-joint-infections/

Kim HN, Kim J, Jang WS, Nam J, Lim CS(2019) Performance evaluation of three rapid antigen tests for the diagnosis of group A Streptococci BMJ Open, 9(8), e025438. https://doi.org/10.1136/bmjopen-2018-025438

Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH(2021) Group A Streptococcal Infections Lollar, R. (2016). K162274 510(k) premarket notification of intent to market Solana Strep Complete Assay FDA Retrieved from https://www.accessdata.fda.gov/cdrh_docs/pdf16/K162274.pdf

Luo R, Sickler J, Vahidnia F, Lee YC, Frogner B, Thompson M(2019) Diagnosis and Management of Group a Streptococcal Pharyngitis in the United States, 2011–2015 BMC Infectious Diseases, 19(1), 193. https://doi.org/10.1186/s12879-019-3835-4

McCarty T, White C, Meeder J, Moates D, Pierce H, Edwards W, Hutchinson J, Lee R, Leal Jr S.(2022) Analytical performance and potential clinical utility of the GenMark Dx ePlex® blood culture identification gram-positive panel Diagnostic Microbiology and Infectious Disease, 104(3), 115762

Metlay JP, Waterer GW, Long AC, Anzueto A, Brozek J, Crothers K, Cooley LA, Dean NC, Fine MJ, Flanders SA, Griffin MR, Metersky ML, Musher DM, Restrepo MI, Whitney CG(2019) Diagnosis and Treatment of Adults with Community-acquired Pneumonia. An Official Clinical Practice Guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med, 200(7), e45-e67. https://doi.org/10.1164/rccm.201908-1581ST

Miller JM, Binnicker MJ, Campbell S, Carroll KC, Chapin KC, Gilligan PH, Gonzalez MD, Jerris RC, Kehl SC, Patel R, Pritt BS, Richter SS, Robinson-Dunn B, Schwartzman JD, Snyder JW, Telford S III, Theel ES, Thomson RB, Jr, Weinstein MP, Yao JD(2018) A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: Update by the Infectious Diseases Society of America and the American Society for Microbiology Clinical Infectious Diseases, 67(6), e1-e94. https://doi.org/10.1093/cid/ciy381

Mitchell RB, Archer SM, Ishman SL, Rosenfeld RM, Coles S, Finestone SA, Friedman NR, Giordano T, Hildrew DM, Kim TW, Lloyd RM, Parikh SR, Shulman ST, Walner DL, Walsh SA, Nnacheta LC(2019) Clinical Practice Guideline: Tonsillectomy in Children (Update) Otolaryngol Head Neck Surg, 160(1_suppl), S1-s42. https://doi.org/10.1177/0194599818801757

NICE(2019) Rapid tests for group A streptococcal infections in people with a sore throat https://www.nice.org.uk/guidance/dg38

O. Luiz F, Alves KB, Barros RR(2019) Prevalence and long-term persistence of beta-haemolytic streptococci throat carriage among children and young adults J Med Microbiol, 68(10), 1526-1533. https://doi.org/10.1099/jmm.0.001054

Pediatrics, A. A(2018) Group B Streptococcal Infections In D Kimberlin, M Brady, M Jackson, S Long (Eds.), Red Book Report of the Committee on Infectious Diseases (pp. 762-768). American Academy of Pediatrics. https://redbook.solutions.aap.org/chapter.aspx?sectionid=189640188&bookid=2205

Puopolo KM, Lynfield R, Cummings JJ(2019) Management of Infants at Risk for Group B Streptococcal Disease Pediatrics, 144(2), e20191881. https://doi.org/10.1542/peds.2019-1881

Puopolo KM, Madoff LC, Baker CJ(2022) Group B streptococcal infection in pregnant women. Wolters Kluwer https://www.uptodate.com/contents/group-b-streptococcal-infection-in-pregnant-women

Raignoux J, Benard M, Huo Yung Kai S, Dicky O, Berrebi A, Bibet L, Chetouani AS, Marty N, Cavalie L, Casper C, Assouline-Azogui C(2016) Is rapid intrapartum vaginal screening test of group B streptococci (GBS) during partum useful in identifying infants developing early-onset GBS sepsis in postpartum period? Arch Pediatr, 23(9) 899-907.https://doi.org/10.1016/j.arcped.2016.06.003

Rantala S(2014) Streptococcus dysgalactiae subsp. equisimilis bacteremia: an emerging infection Eur J Clin Microbiol Infect Dis, 33(8), 1303-1310. https://doi.org/10.1007/s10096-014-2092-0

Schwartz B, Facklam RR, Breiman RF(1990) Changing epidemiology of group A streptococcal infection in the USA Lancet, 336(8724), 1167-1171

Short S, Bashir H, Marshall P, Miller N, Olmschenk D, Prigge K, Solyntjes L(2017) Diagnosis and Treatment of Respiratory Illness in Children and Adults (5th ed.) Institute for Clinical Systems Improvement. https://www.icsi.org/wp-content/uploads/2019/01/RespIllness.pdf

Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C(2012) Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis update by the Infectious Diseases Society of America Clin Infect Dis, 55(10), e86-102. https://doi.org/10.1093/cid/cis629

Spellerberg B, Brandt C(2016) Laboratory Diagnosis of Streptococcus pyogenes (group A streptococci). In JJ Ferretti, DL Stevens, VA Fischetti(Eds) Streptococcus pyogenes:Basic Biology to Clinical Manifestations. University of Oklahoma Health Sciences Center

Steer A, Gibofsky A(2022) Acute rheumatic fever: Clinical manifestations and diagnosis https://www.uptodate.com/contents/acute-rheumatic-fever-clinical-manifestations-and-diagnosis

Steer AC, Smeesters PR, Curtis N(2015) Streptococcal Serology: Secrets for the Specialist. Pediatr Infect Dis J, 34(11), 1250-1252 https://doi.org/10.1097/inf.0000000000000881

Stevens DL, Bisno AL, Chambers HF, Dellinger EP, Goldstein EJC, Gorbach SL, Hirschmann JV, Kaplan SL, Montoya JG, Wade JC(2014) Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: Update by the Infectious Diseases Society of America Clinical Infectious Diseases, 59(2), e10-e52. https://doi.org/10.1093/cid/ciu296

Stevens DL, Bryant A(2022) Group A streptococcus: Virulence factors and pathogenic mechanisms https://www.uptodate.com/contents/group-a-streptococcus-virulence-factors-and-pathogenic-mechanisms

Uphoff, TS, Buchan BW, Ledeboer NA, Granato PA, Daly JA, Marti TN(2016) Multicenter Evaluation of the Solana Group A Streptococcus Assay: Comparison with Culture J Clin Microbiol, 54(9), 2388-2390. https://doi.org/10.1128/jcm.01268-16

Wald, ER(2022) Group A streptococcal tonsillopharyngitis in children and adolescents Clinical features and diagnosis. Wolters Kluwer. https://www.uptodate.com/contents/group-a-streptococcal-tonsillopharyngitis-in-children-and-adolescents-clinical-features-and-diagnosis

Weinzierl EP, Jerris RC, Gonzalez MD, Piccini JA, Rogers, BB(2018) Comparison of Alere i Strep A Rapid Molecular Assay With Rapid Antigen Testing and Culture in a Pediatric Outpatient Setting American Journal of Clinical Pathology, aqy038-aqy038. https://doi.org/10.1093/ajcp/aqy038

Wessels MR(2022) Group C and group G streptococcal infection https://www.uptodate.com/contents/group-c-and-group-g-streptococcal-infection
Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2025 American Medical Association.