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Streptococcal pharyngitis

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Streptococcal pharyngitis
Synonyms Streptococcal tonsillitis, streptococcal sore throat, strep
A set of large tonsils in the back of the throat covered in white exudate
A culture positive case of streptococcal pharyngitis with typical tonsillar exudate in a 16-year-old.
Specialty Infectious disease
Symptoms Fever, sore throat, large lymph nodes[1]
Usual onset 1–3 days after exposure[2][3]
Duration 7–10 days[2][3]
Causes Group A streptococcus[1]
Diagnostic method Throat culture, strep test[1]
Prevention Handwashing[1]
Treatment Paracetamol (acetaminophen), NSAIDs, antibiotics[4][1]
Frequency 5 to 40% of sore throats[5][6]
[edit on Wikidata]

Streptococcal pharyngitis, also known as strep throat, is an infection of the back of the throat including the tonsils caused by group A streptococcus (GAS).[1] Common symptoms include fever, sore throat, red tonsils, and enlarged lymph nodes in the neck.[1] A headache, and nausea or vomiting may also occur.[1] Some develop a sandpaper-like rash which is known as scarlet fever.[2] Symptoms typically begin one to three days after exposure and last seven to ten days.[2][3]

Strep throat is spread by respiratory droplets from an infected person.[1] It may be spread directly or by touching something that has droplets on it and then touching the mouth, nose, or eyes.[1] Some people may carry the bacteria without symptoms.[1] It may also be spread by skin infected with group A strep.[1] The diagnosis is made based on the results of a rapid antigen detection test or throat culture in those who have symptoms.[7]

Prevention is by washing hands and not sharing eating utensils.[1] There is no vaccine for the disease.[1] Treatment with antibiotics is only recommended in those with a confirmed diagnosis.[7] Those infected should stay away from other people for at least 24 hours after starting treatment.[1] Pain can be treated with paracetamol (acetaminophen) and nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen.[4]

Strep throat is a common bacterial infection in children.[2] It is the cause of 15–40% of sore throats among children[5][8] and 5–15% among adults.[6] Cases are more common in late winter and early spring.[8] Potential complications include rheumatic fever and peritonsillar abscess.[1][2]

Signs and symptoms

The typical signs and symptoms of streptococcal pharyngitis are a sore throat, fever of greater than 38 °C (100 °F), tonsillar exudates (pus on the tonsils), and large cervical lymph nodes.[8]

Other symptoms include: headache, nausea and vomiting, abdominal pain,[9] muscle pain,[10] or a scarlatiniform rash or palatal petechiae, the latter being an uncommon but highly specific finding.[8]

Symptoms typically begin one to three days after exposure and last seven to ten days.[3][8]

Strep throat is unlikely when any of the symptoms of red eyes, hoarseness, runny nose, or mouth ulcers are present. It is also unlikely when there is no fever.[6]

Cause

Strep throat is caused by group A beta-hemolytic streptococcus (GAS or S. pyogenes).[11] Other bacteria such as non–group A beta-hemolytic streptococci and fusobacterium may also cause pharyngitis.[8][10] It is spread by direct, close contact with an infected person; thus crowding, as may be found in the military and schools, increases the rate of transmission.[10][12] Dried bacteria in dust are not infectious, although moist bacteria on toothbrushes or similar items can persist for up to fifteen days.[10] Contaminated food can result in outbreaks, but this is rare.[10] Of children with no signs or symptoms, 12% carry GAS in their pharynx,[5] and, after treatment, approximately 15% of those remain positive, and are true "carriers".[13]

Diagnosis

Modified Centor score
Points Probability of Strep Management
1 or fewer <10% No antibiotic or culture needed
2 11–17% Antibiotic based on culture or RADT
3 28–35%
4 or 5 52% Empiric antibiotics

A number of scoring systems exist to help with diagnosis; however, their use is controversial due to insufficient accuracy.[14] The modified Centor criteria are a set of five criteria; the total score indicates the probability of a streptococcal infection.[8]

One point is given for each of the criteria:[8]

  • 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)

A score of one may indicated no treatment or culture is needed, or it may indicate the need to perform further testing if other high risk factors exist, such as a family member having the disease.[8]

The Infectious Disease Society of America recommends against empirical treatment and considers antibiotics only appropriate when given after a positive test.[6] Testing is not needed in children under three as both group A strep and rheumatic fever are rare, unless a child has a sibling with the disease.[6]

Laboratory testing

A throat culture is the gold standard[15] for the diagnosis of streptococcal pharyngitis, with a sensitivity of 90–95%.[8] A rapid strep test (also called rapid antigen detection testing or RADT) may also be used. While the rapid strep test is quicker, it has a lower sensitivity (70%) and statistically equal specificity (98%) as a throat culture.[8] In areas of the world where rheumatic fever is uncommon, a negative rapid strep test is sufficient to rule out the disease.[16]

A positive throat culture or RADT in association with symptoms establishes a positive diagnosis in those in which the diagnosis is in doubt.[17] In adults, a negative RADT is sufficient to rule out the diagnosis. However, in children a throat culture is recommended to confirm the result.[6] Asymptomatic individuals should not be routinely tested with a throat culture or RADT because a certain percentage of the population persistently "carries" the streptococcal bacteria in their throat without any harmful results.[17]

Differential diagnosis

As the symptoms of streptococcal pharyngitis overlap with other conditions, it can be difficult to make the diagnosis clinically.[8] Coughing, nasal discharge, diarrhea, and red, irritated eyes in addition to fever and sore throat are more indicative of a viral sore throat than of strep throat.[8] The presence of marked lymph node enlargement along with sore throat, fever, and tonsillar enlargement may also occur in infectious mononucleosis.[18]

Prevention

Tonsillectomy may be a reasonable preventive measure in those with frequent throat infections (more than three a year).[19] However, the benefits are small and episodes typically lessen in time regardless of measures taken.[20][21][22] Recurrent episodes of pharyngitis which test positive for GAS may also represent a person who is a chronic carrier of GAS who is getting recurrent viral infections.[6] Treating people who have been exposed but who are without symptoms is not recommended.[6] Treating people who are carriers of GAS is not recommended as the risk of spread and complications is low.[6]

Treatment

Untreated streptococcal pharyngitis usually resolves within a few days.[8] Treatment with antibiotics shortens the duration of the acute illness by about 16 hours.[8] The primary reason for treatment with antibiotics is to reduce the risk of complications such as rheumatic fever and retropharyngeal abscesses;[8] antibiotics are effective if given within 9 days of the onset of symptoms.[11]

Pain medication

Pain medication such as NSAIDs and paracetamol (acetaminophen) helps in the management of pain associated with strep throat.[23] Viscous lidocaine may also be useful.[24] While steroids may help with the pain,[11][25] they are not routinely recommended.[6] Aspirin may be used in adults but is not recommended in children due to the risk of Reye syndrome.[11]

Antibiotics

The antibiotic of choice in the United States for streptococcal pharyngitis is penicillin V, due to safety, cost, and effectiveness.[8] Amoxicillin is preferred in Europe.[26] In India, where the risk of rheumatic fever is higher, intramuscular benzathine penicillin G is the first choice for treatment.[11]

Appropriate antibiotics decrease the average 3–5 day duration of symptoms by about one day, and also reduce contagiousness.[17] They are primarily prescribed to reduce rare complications such as rheumatic fever and peritonsillar abscess.[27] The arguments in favor of antibiotic treatment should be balanced by the consideration of possible side effects,[10] and it is reasonable to suggest that no antimicrobial treatment be given to healthy adults who have adverse reactions to medication or those at low risk of complications.[27][28] Antibiotics are prescribed for strep throat at a higher rate than would be expected from how common it is.[29]

Erythromycin and other macrolides or clindamycin are recommended for people with severe penicillin allergies.[8][6] First-generation cephalosporins may be used in those with less severe allergies[8] and some evidence supports cephalosporins as superior to penicillin.[30][31] Streptococcal infections may also lead to acute glomerulonephritis; however, the incidence of this side effect is not reduced by the use of antibiotics.[11]

Prognosis

The symptoms of strep throat usually improve within three to five days, irrespective of treatment.[17] Treatment with antibiotics reduces the risk of complications and transmission; children may return to school 24 hours after antibiotics are administered.[8] The risk of complications in adults is low.[6] In children, acute rheumatic fever is rare in most of the developed world. It is, however, the leading cause of acquired heart disease in India, sub-Saharan Africa and some parts of Australia.[6]

Complications arising from streptococcal throat infections include:

The economic cost of the disease in the United States in children is approximately $350 million annually.[6]

Epidemiology

Pharyngitis, the broader category into which Streptococcal pharyngitis falls, is diagnosed in 11 million people annually in the United States.[8] It is the cause of 15–40% of sore throats among children[5][8] and 5–15% in adults.[6] Cases usually occur in late winter and early spring.[8]

References

  1. ^ a b c d e f g h i j k l m n o p "Is It Strep Throat?". CDC. October 19, 2015. Archived from the original on 2 February 2016. Retrieved 2 February 2016. 
  2. ^ a b c d e f Török, edited by David A. Warrell, Timothy M. Cox, John D. Firth ; with guest ed. Estée (2012). Oxford textbook of medicine infection. Oxford: Oxford University Press. pp. 280–281. ISBN 9780191631733. Archived from the original on 2016-10-10. 
  3. ^ a b c d Jr, [edited by] Allan H. Goroll, Albert G. Mulley (2009). Primary care medicine : office evaluation and management of the adult patient (6th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. p. 1408. ISBN 9780781775137. Archived from the original on 2016-09-15. 
  4. ^ a b Weber, R (March 2014). "Pharyngitis". Primary care. 41 (1): 91–8. doi:10.1016/j.pop.2013.10.010. PMID 24439883. 
  5. ^ a b c d Shaikh N, Leonard E, Martin JM (September 2010). "Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis". Pediatrics. 126 (3): e557–64. doi:10.1542/peds.2009-2648. PMID 20696723. 
  6. ^ a b c d e f g h i j k l m n o p q r 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. 55 (10): e86–102. doi:10.1093/cid/cis629. PMID 22965026. 
  7. ^ a b Harris, AM; Hicks, LA; Qaseem, A (19 January 2016). "Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention". Annals of Internal Medicine. 164: 425. doi:10.7326/M15-1840. PMID 26785402. 
  8. ^ a b c d e f g h i j k l m n o p q r s t u v w x Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician. 79 (5): 383–90. PMID 19275067. Archived from the original on 2015-02-08. 
  9. ^ a b Brook I, Dohar JE (December 2006). "Management of group A beta-hemolytic streptococcal pharyngotonsillitis in children". J Fam Pract. 55 (12): S1–11; quiz S12. PMID 17137534. 
  10. ^ a b c d e f Hayes CS, Williamson H (April 2001). "Management of Group A beta-hemolytic streptococcal pharyngitis". Am Fam Physician. 63 (8): 1557–64. PMID 11327431. Archived from the original on 2008-05-16. 
  11. ^ a b c d e f Baltimore RS (February 2010). "Re-evaluation of antibiotic treatment of streptococcal pharyngitis". Curr. Opin. Pediatr. 22 (1): 77–82. doi:10.1097/MOP.0b013e32833502e7. PMID 19996970. 
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  13. ^ Rakel, edited by Robert E. Rakel, David P. (2011). Textbook of family medicine (8th ed.). Philadelphia, PA.: Elsevier Saunders. p. 331. ISBN 9781437711608. Archived from the original on 2017-09-08. 
  14. ^ Cohen, JF; Cohen, R; Levy, C; Thollot, F; Benani, M; Bidet, P; Chalumeau, M (6 January 2015). "Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study". Canadian Medical Association Journal. 187 (1): 23–32. doi:10.1503/cmaj.140772. PMC 4284164Freely accessible. PMID 25487666. 
  15. ^ Smith, Ellen Reid; Kahan, Scott; Miller, Redonda G. (2008). In A Page Signs & Symptoms. In a Page Series. Hagerstown, Maryland: Lippincott Williams & Wilkins. p. 312. ISBN 0-7817-7043-2. 
  16. ^ Lean, WL; Arnup, S; Danchin, M; Steer, AC (October 2014). "Rapid diagnostic tests for group A streptococcal pharyngitis: a meta-analysis". Pediatrics. 134 (4): 771–81. doi:10.1542/peds.2014-1094. PMID 25201792. 
  17. ^ a b c d Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH (July 2002). "Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America". Clin. Infect. Dis. 35 (2): 113–25. doi:10.1086/340949. PMID 12087516. 
  18. ^ Ebell MH (2004). "Epstein-Barr virus infectious mononucleosis". Am Fam Physician. 70 (7): 1279–87. PMID 15508538. Archived from the original on 2008-07-24. 
  19. ^ Johnson BC, Alvi A (March 2003). "Cost-effective workup for tonsillitis. Testing, treatment, and potential complications". Postgrad Med. 113 (3): 115–8, 121. doi:10.3810/pgm.2003.03.1391. PMID 12647478. 
  20. ^ van Staaij BK, van den Akker EH, van der Heijden GJ, Schilder AG, Hoes AW (January 2005). "Adenotonsillectomy for upper respiratory infections: evidence based?". Archives of Disease in Childhood. 90 (1): 19–25. doi:10.1136/adc.2003.047530. PMC 1720065Freely accessible. PMID 15613505. 
  21. ^ Burton, MJ; Glasziou, PP; Chong, LY; Venekamp, RP (19 November 2014). "Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis". The Cochrane database of systematic reviews (11): CD001802. doi:10.1002/14651858.CD001802.pub3. PMID 25407135. 
  22. ^ Morad, Anna; Sathe, Nila A.; Francis, David O.; McPheeters, Melissa L.; Chinnadurai, Sivakumar (17 January 2017). "Tonsillectomy Versus Watchful Waiting for Recurrent Throat Infection: A Systematic Review". Pediatrics. 139 (2): e20163490. doi:10.1542/peds.2016-3490. ISSN 0031-4005. PMC 5260157Freely accessible. PMID 28096515. Archived from the original on 13 August 2017. 
  23. ^ Thomas M, Del Mar C, Glasziou P (October 2000). "How effective are treatments other than antibiotics for acute sore throat?". Br J Gen Pract. 50 (459): 817–20. PMC 1313826Freely accessible. PMID 11127175. 
  24. ^ "Generic Name: Lidocaine Viscous (Xylocaine Viscous) side effects, medical uses, and drug interactions". MedicineNet.com. Archived from the original on 2010-04-08. Retrieved 2010-05-07. 
  25. ^ Wing, A; Villa-Roel, C; Yeh, B; Eskin, B; Buckingham, J; Rowe, BH (May 2010). "Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature". Academic Emergency Medicine. 17 (5): 476–83. doi:10.1111/j.1553-2712.2010.00723.x. PMID 20536799. 
  26. ^ Bonsignori F, Chiappini E, De Martino M (2010). "The infections of the upper respiratory tract in children". Int J Immunopathol Pharmacol. 23 (1 Suppl): 16–9. PMID 20152073. 
  27. ^ a b Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR (March 2001). "Principles of appropriate antibiotic use for acute pharyngitis in adults" (PDF). Ann Intern Med. 134 (6): 506–8. doi:10.7326/0003-4819-134-6-200103200-00018. PMID 11255529. Archived (PDF) from the original on 2004-02-04. [needs update?]
  28. ^ Hildreth, AF; Takhar, S; Clark, MA; Hatten, B (September 2015). "Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department". Emergency medicine practice. 17 (9): 1–16; quiz 16–7. PMID 26276908. (Subscription required (help)). 
  29. ^ Linder JA, Bates DW, Lee GM, Finkelstein JA (November 2005). "Antibiotic treatment of children with sore throat". J Am Med Assoc. 294 (18): 2315–22. doi:10.1001/jama.294.18.2315. PMID 16278359. 
  30. ^ Pichichero, M; Casey, J (June 2006). "Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis". European Journal of Clinical Microbiology & Infectious Diseases. 25 (6): 354–64. doi:10.1007/s10096-006-0154-7. PMID 16767482. 
  31. ^ van Driel, ML; De Sutter, AI; Habraken, H; Thorning, S; Christiaens, T (11 September 2016). "Different antibiotic treatments for group A streptococcal pharyngitis". The Cochrane database of systematic reviews. 9: CD004406. doi:10.1002/14651858.CD004406.pub4. PMID 27614728. 
  32. ^ a b "UpToDate Inc". Archived from the original on 2008-12-08. 
  33. ^ Stevens DL, Tanner MH, Winship J, et al. (July 1989). "Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A". N. Engl. J. Med. 321 (1): 1–7. doi:10.1056/NEJM198907063210101. PMID 2659990. 
  34. ^ a b Hahn RG, Knox LM, Forman TA (May 2005). "Evaluation of poststreptococcal illness". Am Fam Physician. 71 (10): 1949–54. PMID 15926411. 

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