Streptococcal pharyngitis: Difference between revisions
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==Background== | ==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 | ||
*Accounts for only 15-30% of [[pharyngitis]] | *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== | ==Clinical Features== | ||
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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]]'' | |||
{{Modified Centor Criteria}} | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Acute rheumatic fever]] | |||
*[[Scarlet fever]] | |||
*Suppurative complications | |||
**[[Peritonsillar abscess]] | |||
**[[Mastoiditis]] | |||
{{Sore throat DDX}} | {{Sore throat DDX}} | ||
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==Evaluation== | ==Evaluation== | ||
{{ | {{RADT algorithm}} | ||
==Management== | ==Management== | ||
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===[[Steroids]]=== | ===[[Steroids]]=== | ||
* | *Consider single dose of [[dexamethasone]] 0.6mg/kg PO (Max = 10mg)<ref>[[EBQ:TOAST Trial]]</ref> | ||
==Disposition== | ==Disposition== |
Revision as of 20:40, 6 October 2019
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
- Sore throat
- Painful swallowing
- Fever
- Nausea and vomiting
- Tonsillar exudate
- Palatal petechiae
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]
- 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^
- Subtract a point if age >44
Points | Probability of Streptococcal pharyngitis |
---|---|
1 or fewer | <10% |
2 | 11–17% |
3 | 28–35% |
4 or 5 | 52% |
Differential Diagnosis
- Acute rheumatic fever
- Scarlet fever
- Suppurative complications
Acute Sore Throat
Bacterial infections
- Streptococcal pharyngitis (Strep Throat)
- Neisseria gonorrhoeae
- Diphtheria (C. diptheriae)
- Bacterial Tracheitis
Viral infections
- Infectious mononucleosis (EBV)
- Patients with peritonsillar abscess have a 20% incidence of mononucleosis [2]
- Laryngitis
- Acute Bronchitis
- Rhinovirus
- Coronavirus
- Adenovirus
- Herpesvirus
- Influenza virus
- Coxsackie virus
- HIV (Acute Retroviral Syndrome)
Noninfectious
Other
- Deep neck space infection
- Peritonsillar Abscess (PTA)
- Epiglottitis
- Kawasaki disease
- Penetrating injury
- Caustic ingestion
- Lemierre's syndrome
- Peritonsillar cellulitis
- Lymphoma
- Internal carotid artery aneurysm
- Oral Thrush
- Parotitis
- Post-tonsillectomy hemorrhage
- Vincent's angina
- Acute necrotizing ulcerative gingivitis
Oral rashes and lesions
- Angioedema
- Aphthous stomatitis
- Herpes gingivostomatitis
- Herpes labialis
- Measles (Koplik's spots)
- Perioral dermatitis
- Oral thrush
- Steven Johnson syndrome
- Streptococcal pharyngitis
- Tongue diagnoses
- Vincent's angina
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) |
|
<3 years old |
|
CENTOR = 1 |
|
None of the above with CENTOR ≥2 |
|
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
- Consider single dose of dexamethasone 0.6mg/kg PO (Max = 10mg)[7]
Disposition
- Discharge
Complications
- Acute rheumatic fever
- Scarlet fever
- Toxic shock syndrome
- Post-streptococcal glomerular nephritis
- PANDAS syndrome
- Peritonsillar abscess
- Cervical lymphadenitis
- Mastoiditis
See Also
References
- ↑ 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.
- ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
- ↑ 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
- ↑ David Cisewski An Understated Myth? Strep Throat & Rheumatic Fever
- ↑ 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
- ↑ 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
- ↑ EBQ:TOAST Trial