Streptococcal pharyngitis: Difference between revisions
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==Background==
==Background==
*Peak in 5-15yr old
[[File:Gray1014.png|thumb|Anatomy of the posterior pharynx.]]
*Rare in <2yr of age
*Peak in 5-15yr old<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>
*Accounts for only 15-30% of pharyngitis
*Rare in <2yr of age<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>
*Accounts for only 15-30% of [[pharyngitis]]<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>
*Caused by [[ S. pyogenes]] (Group A strep)<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>
*Peak season is late winter / early spring<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>
*Transmission is respiratory secretions<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>
*Incubation period is 24-72 hours<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>
*Antibiotics shorten symptoms by 16 hours<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>


==Clinical Features==
==Clinical Features==
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*[[Nausea and vomiting]]
*[[Nausea and vomiting]]
*Tonsillar exudate
*Tonsillar exudate
*Palatal petechiae
*Palatal [[petechiae]]


===Complications===
''Should NOT have a rash; if have scarlatiniform rash consider [[scarlet fever]]''
 
{{Modified Centor Criteria}}
 
==Differential Diagnosis==
*[[Acute rheumatic fever]]
*[[Acute rheumatic fever]]
*[[Scarlet fever]]
*[[Scarlet fever]]
*[[Toxic shock syndrome]]
*Suppurative complications
*[[Post-streptococcal glomerular nephritis]]
**[[Peritonsillar abscess]]
*PANDAS syndrome
**[[Mastoiditis]]
*[[Peritonsillar abscess]]
*Cervical lymphadenitis
*[[Mastoiditis]]


==Differential Diagnosis==
{{Sore throat DDX}}
{{Sore throat DDX}}


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==Evaluation==
==Evaluation==
===Modified Centor Criteria<ref name=Review09>Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.</ref>===
*Per a 2016 Cochrane Review of rapid strep tests in children, tests on average had a specificity of 95% and sensitivity of 86%, regardless of type of rapid strep test used (enzyme immunoassays or optical immunoassays).<ref>Cohen JF, Bertille N, Cohen R, Chalumeau M. What is the performance of rapid tests for the diagnosis of strep throat in children?. Cochrane Review. Published 4 July 2016. https://www.cochrane.org/CD010502/ARI_what-performance-rapid-tests-diagnosis-strep-throat-children</ref>
One point is given for each of the criteria:<ref name=Review09/>
*Absence of a cough
*Swollen and tender cervical lymph nodes
*Temperature >38.0 °C (100.4 °F)
*Tonsillar exudate or swelling
*Age less than 15 (a point is subtracted if age >44)^
 
{| class="wikitable"
|+ Modified Centor score
!Points||Probability of Strep||Management
|-
| 1 or fewer|| <10%||No antibiotic or culture needed
|-
| 2        ||11–17%||rowspan="2"|Antibiotic based on rapid strep or culture
|-
| 3        ||28–35%
|-
| 4 or 5  ||52%||Empiric antibiotics
|}


^Testing is not needed in children <3 years old as both group A strep and [[rheumatic fever]] are rare, except if they have a sibling with the disease.<ref name=IDSA2012>Shulman, ST; Bisno, AL; Clegg, HW; Gerber, MA; Kaplan, EL; Lee, G; Martin, JM; Van Beneden, C (Sep 9, 2012). "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 : an official publication of the Infectious Diseases Society of America 55 (10): e86–102. doi:10.1093/cid/cis629. PMID 22965026.</ref>
{{RADT algorithm}}


==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==
*Discharge
*Discharge
==Complications==
*[[Acute rheumatic fever]]
*[[Scarlet fever]]
*[[Toxic shock syndrome]]
*[[Post-streptococcal glomerular nephritis]]
*[[Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS)|PANDAS syndrome]]
*[[Peritonsillar abscess]]
*Cervical [[lymphadenitis]]
*[[Mastoiditis]]


==See Also==
==See Also==

Latest revision as of 21:28, 4 March 2023

Background

Anatomy of the posterior pharynx.
  • Peak in 5-15yr old[1]
  • Rare in <2yr of age[1]
  • Accounts for only 15-30% of pharyngitis[1]
  • Caused by S. pyogenes (Group A strep)[1]
  • Peak season is late winter / early spring[1]
  • Transmission is respiratory secretions[1]
  • Incubation period is 24-72 hours[1]
  • Antibiotics shorten symptoms by 16 hours[1]

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

  • Per a 2016 Cochrane Review of rapid strep tests in children, tests on average had a specificity of 95% and sensitivity of 86%, regardless of type of rapid strep test used (enzyme immunoassays or optical immunoassays).[3]

Rapid Antigen Detection Test Algorithm for Acute Pharyngitis[4]

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[5].
    • 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:

Penicillin allergic (mild):

Penicillin allergic (anaphylaxis):[6]

  • Clindamycin 7 mg/kg/dose TID (maximum = 300 mg/dose) x 10 days[12]
  • Azithromycin 12 mg/kg PO once (maximum = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days[13]
  • Clarithromycin 7.5 mg/kg/dose PO BID (maximum = 250 mg/dose) x 10 days[14]

Steroids

Disposition

  • Discharge

Complications

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 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. ↑ Cohen JF, Bertille N, Cohen R, Chalumeau M. What is the performance of rapid tests for the diagnosis of strep throat in children?. Cochrane Review. Published 4 July 2016. https://www.cochrane.org/CD010502/ARI_what-performance-rapid-tests-diagnosis-strep-throat-children
  4. ↑ 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
  5. ↑ David Cisewski An Understated Myth? Strep Throat & Rheumatic Fever
  6. ↑ 6.0 6.1 6.2 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
  7. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  8. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  9. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  10. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  11. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  12. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  13. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  14. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  15. ↑ EBQ:TOAST Trial
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