Streptococcal pharyngitis: Difference between revisions
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==Background<ref>Choby BA. Amer Fam Phys. 2009, 79(5), 383-90.</ref>==
==Background<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>==
*Peak in 5-15yr old
*Peak in 5-15yr old
*Rare in <2yr of age
*Rare in <2yr of age
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*[[Nausea and vomiting]]
*[[Nausea and vomiting]]
*Tonsillar exudate
*Tonsillar exudate
*Palatal petechiae
*Palatal [[petechiae]]


''Should NOT have a rash; if have scarlatiniform rash consider [[scarlet fever]]''
''Should NOT have a rash; if have scarlatiniform rash consider [[scarlet fever]]''
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==Evaluation==
==Evaluation==
''Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended''
{{RADT algorithm}}
 
===Rapid Antigen Detection Test Algorithm (RADT)<ref>Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82</ref>===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Category'''
| align="center" style="background:#f0f0f0;"|'''Testing/Treatment ?'''
|-
| Clinical features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers)||
*None
|-
| <3 years old||
*None
**Unless they have special risk factors, such as an older sibling with GAS infection
|-
| CENTOR = 1||
*None
|-
| None of the above with CENTOR >=2||
*Send rapid antigen detection test
**Positive = treat
**Negative
***Children and adolescents
****Send back up throat culture (treat later, if positive)
***Adults
****None (no need for back up throat culture)
|}


==Management==
==Management==
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===[[Steroids]]===
===[[Steroids]]===
*Single dose of [[dexamethasone]] shortens duration of pain<ref>Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012 Oct 17;10:CD008268. PMID: 23076943.</ref>
*Consider single dose of [[dexamethasone]] 0.6mg/kg PO (Max = 10mg)<ref>[[EBQ:TOAST Trial]]</ref>
**[[Dexamethasone]] 0.6mg/kg PO - maximum of 10mg


==Disposition==
==Disposition==
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*[[Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS)|PANDAS syndrome]]
*[[Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS)|PANDAS syndrome]]
*[[Peritonsillar abscess]]
*[[Peritonsillar abscess]]
*Cervical lymphadenitis
*Cervical [[lymphadenitis]]
*[[Mastoiditis]]
*[[Mastoiditis]]


Revision as of 16:37, 29 October 2020

Background[1]

  • Peak in 5-15yr old
  • Rare in <2yr of age
  • Accounts for only 15-30% of pharyngitis
  • Caused by S. pyogenes (Group A strep)
  • Peak season is late winter / early spring
  • Transmission is respiratory secretions
  • Incubation period is 24-72 hours
  • Antibiotics shorten symptoms by 16 hours

Clinical Features

culture positive strep pharyngitis with typical tonsillar exudate

Should NOT have a rash; if have scarlatiniform rash consider scarlet fever

Modified Centor Criteria[1]

One point is given for each of the criteria:[1]

  1. Absence of a cough
  2. Swollen and tender cervical lymph nodes
  3. Temperature >38.0 °C (100.4 °F)
  4. Tonsillar exudate or swelling
  5. Age less than 15^
    • Subtract a point if age >44
Modified Centor score
Points Probability of Streptococcal pharyngitis
1 or fewer <10%
2 11–17%
3 28–35%
4 or 5 52%

Differential Diagnosis

Acute Sore Throat

Bacterial infections

Viral infections

Noninfectious

Other

Oral rashes and lesions

Evaluation

Rapid Antigen Detection Test Algorithm for Acute Pharyngitis[3]

Category Testing and Treatment
Clinical features strongly suggesting viral etiology (eg. cough, rhinorrhea, hoarseness, oral ulcers)
  • None
<3 years old
  • None because immature immune system not mature enough to develop anti-streptolysin O (ASO) antibodies and acute rheumatic fever[4].
    • Unless they have a special risk factor (e.g. older sibling with GAS infection)
CENTOR = 1
  • None
None of the above with CENTOR ≥2
  • Send rapid antigen detection test
    • Positive = treat
    • Negative
      • Children and adolescents
        • Send back up throat culture (treat later, if positive)
      • Adults
        • None (no need for back up throat culture)

Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended

Management

Antibiotics

Treatment can be delayed for up to 9 days and still prevent major sequelae

Penicillin Options:[5]

  • Penicillin V 250mg PO BID x 10d (child) or 500mg BID x 10d (adolescent or adult)
  • Bicillin L-A <27 kg: 0.6 million units; ≥27 kg: 1.2 million units IM x 1
  • Amoxicillin 500-875 mg PO q12h or 250-500 PO q8h for 10d[6]

Penicillin allergic (mild):[5]

  • Cefuroxime 10mg/kg PO QID x 10d (child) or 250mg PO BID x 4d
  • Cefixime 400mg/day PO in single daily dose x10d or divided q12hr x10d

Penicillin allergic (anaphylaxis):[5]

  • Clindamycin 7.5mg/kg PO QID x 10d (child) or 450mg PO TID x 10d OR
  • Azithromycin 12mg/kg QD (child) or 500mg on day 1; then 250mg on days 2-5

Steroids

Disposition

  • Discharge

Complications

See Also

References

  1. ↑ 1.0 1.1 1.2 Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.
  2. ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  3. ↑ Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82
  4. ↑ David Cisewski An Understated Myth? Strep Throat & Rheumatic Fever
  5. ↑ 5.0 5.1 5.2 Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82
  6. ↑ Shah, U. K., MD. (2020, October 14). Tonsillitis and Pharyngitis Organism-Specific Therapy: Specific Organisms and Therapeutic Regimens. Emedicine. https://emedicine.medscape.com/article/2011872-overview
  7. ↑ EBQ:TOAST Trial
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