Streptococcal pharyngitis

Background

• Strep pharyngitis
  • Peak in 5-15yr old
  • Rare in <2yr of age
  • Accounts for only 15-30% of pharyngitis

Clinical Features

• Sore throat
• Painful swallowing
• Fever
• N/V
• Tonsillar exudate
• Palatal petechiae

Diagnosis - Centor Criteria

1. History of fever
2. Absence of cough
3. Lymphadenopathy
4. Tonsillar exudate or swelling

Points	Treatment	Likeilihood of Strep
4	Rx without testing	50% PPV
3	Rapid Strep Test	40% PPV
2	Rapid Strep Test
1	Do not test/treat
0	Do not test/treat	80% NPV

Differential Diagnosis

Pharyngitis

• Viral pharyngitis
• Retropharyngeal abscess
• CMV pharyngitis
• Gonococcal pharyngitis

Others

• EBV pharyngitis
• Acute HIV
• Lemierre's Syndrome
• PTA
• Retropharyngeal Abscess
• Ludwig's Angina
• Epiglottitis

Treatment

Antibiotics

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

Penicillin Options:

• 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 50 mg/kg once daily (maximum = 1000 mg) for 10 days

Penicillin allergic (mild):

• Cephalexin 20 mg per kg PO BID (maximum 500 mg per dose) x 10 days
• Cefadroxil 30 mg per kg PO QD (maximum 1 g daily) x 10 days

Penicillin allergic (anaphylaxis):

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

Pediatric Dosing:

• Amoxicillin 50mg/kg PO once daily x 10 days (max 1000mg)
• Penicillin V <27kg: 250mg PO BID-TID x 10 days; >27kg: 500mg PO BID-TID x 10 days
• Penicillin G Benzathine <27kg: 600,000 units IM x 1; >27kg: 1.2 million units IM x 1
• PCN allergy (mild): Cephalexin 20mg/kg PO BID x 10 days (max 500mg/dose)
• PCN allergy (mild): Cefadroxil 30mg/kg PO daily x 10 days (max 1g)
• PCN allergy (severe): Azithromycin 12mg/kg PO day 1 (max 500mg), then 6mg/kg daily x 4 days (max 250mg)
• PCN allergy (severe): Clindamycin 7mg/kg/dose PO TID x 10 days (max 300mg/dose)
• PCN allergy (severe): Clarithromycin 7.5mg/kg PO BID x 10 days (max 250mg/dose)

• Clindamycin 7mg/kg/dose PO q8h x 10 days; Max: 300mg/dose
• Azithromycin Children ≥2 years and Adolescents: Oral: 12mg/kg/dose once daily for 5 days (maximum: 500mg daily)
• Amoxicillin 50mg/kg PO q24h x 10 days; Max: 1000mg/day
• Clarithromycin >6mo: 15mg/kg/day PO divided q12h x 7-10d
• Cephalexin 40mg/kg/day PO divided q12h x 10 days; Max: 500mg/dose
• Cefpodoxime 100mg q 12 h for 5-10 days
• Cefuroxime 250mg PO bid x10 days
• Cefuroxime 250mg PO bid x10 days

Steroids

• Single dose of dexamethasone shortens duration of pain
• Dexamethasone 0.6mg/kg PO

See Also

• Peritonsilar Abscess
• Sore Throat

External Links

• SmartEM Pharyngitis

Source

• Tintinalli
• Rosen's
• Logan LK, McAuley JB, Shulman ST. [Macrolide treatment failure in streptococcal pharyngitis resulting in acute rheumatic Fever]. Pediatrics. 2012 Mar;129(3):e798-802. Epub 2012 Feb 6.