pediatric housecalls Robert R. Jarrett M.D. M.B.A. FAAP

Group A Strep Sore Throat – Practice Guidelines

The billions of sore throats in the world every year are almost all caused by viruses which: means they will resolve on their own, no antibiotics will help and, in fact, may even last longer if we fool around trying to fuss with them. Notice I said “almost” because there is a tiny sub-group of them caused by GAS (group A Streptococcus) which causes physicians grief in trying to diagnose and treat.

You probably have noticed that some doctors meticulously examine the throat, feel neck glands, listen to chest and check inside the nose trying to somehow tell if it is a virus or possibly the bacteria. Others, seem to have given up and merely tell you to “say ahh” and leave it at that. Some are good at what they do and others… well, you know.

Tonsillitis caused by GAS is usually treated with antibiotics in children because we’ve found that if we don’t there is a risk of developing Rheumatic Fever. The rest of the 80% of sore throats are almost all caused by viruses which, as I’ve said, antibiotics don’t help.

A new study reported in the Clinic’s of Infectious Disease [September 9, 2012] showed that 70% of all patients seeing their doctor for a sore throat got blasted with antibiotics – despite the fact that only 5% to 15% of sore throats in adults are caused by GAS. Children are where most of the GAS-caused pharyngitis occurs and despite all our efforts, even they are incorrectly treated more than 50% of the time (incidence of GAS is only 20% to 30% in children).

Additionally, the article published new Clinical Practice Guidelines describing practice standards of how doctors should think about, diagnose and treat pharyngitis (sore throat).

So what’s the big deal?

Well if the sore throat is caused by GAS it’s treated with Penicillin or Amoxicillin if not then there is no antibiotic treatment. We’ve talked previously about how overusing and wasting antibiotics has now put us in a terrible situation with deadly antibiotic resistance.

We don’t want patients to receive (or have to pay for) unnecessary antibiotics. We don’t want them to risk the side effects of them. We don’t want them to risk the chance that their, or their family member’s, next infection will be with the hard to treat resistant, sometimes even fatal, kind of bacteria. And, we don’t want kids to undergo unnecessary tonsil surgery for mis-diagnosed recurrent sore throats.

You can’t always tell just by looking

sore throat exam in boyYou can’t tell with certainty which sore throat is caused by which “bug” because the symptoms overlap; although, there are a few symptoms which “strongly suggest” one over the other. If the child has a cough, runny nose, is hoarse or has ulcers in the mouth in addition to their sore throat then it’s probably being caused by a virus and therefore should not receive antibiotics in most cases.

If instead of those symptoms the pain’s onset is sudden, there is a significant fever present and the swallowing hurts there is a suggestion that it may more likely be caused by GAS. In this case we have a rapid antigen test we can do in the office which is very accurate.

Children younger than 3 years are unlikely to have strep throat, therefore even testing is unnecessary – with the exception of certain circumstances such as an infected older sibling.

Occasionally the specific circumstances might prompt a doctor to want an old fashioned throat culture in order to confirm the quick office test; but, that should only be done in children and adolescents not adults because adults have a low risk of strep throat and even lower risk for complications such as rheumatic fever.

If GAS pharyngitis is confirmed, the treatment of choice remains a 10-day course of penicillin (or amoxicillin), which has a narrow spectrum of activity, is cheaply available, and carries a low risk for adverse events. Other antibiotics are recommended for those with penicillin allergy.

All of these recommendations mentioned in the new article have been thoroughly updated with new research and best practices and replace the 2002 Infectious Diseases Society of America guidelines. They recommend against tonsillectomy for children with repeated throat infection, except in very specific cases (eg, children with obstructive breathing), because the risks of surgery are generally not worth the transient benefit.

Now for those of you who like to know all about this kind of stuff I’ll interpret each of the 13 recommendations for you below. The review panel gave each of them a rating of how strong their recommendation was and how strong the research evidence was that it was based on. (i.e. strong, high)

 

NEW – Clinical Practice Guidelines for the Diagnosis and Management of Group A Streptococcal Pharyngitis

Diagnosis Method

1. Swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features like rhinorrhea, cough, oral ulcers, and/or hoarseness are present. In children and adolescents, negative RADT tests should be backed up by a throat culture (strong, high). Positive RADTs do not necessitate a back-up culture because they are highly specific (strong, high).

2. Routine use of back-up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances, because of the low incidence of GAS pharyngitis in adults and because the risk of subsequent acute rheumatic fever is generally exceptionally low in adults with acute pharyngitis (strong, moderate). Physicians who wish to ensure they are achieving maximal sensitivity in diagnosis may continue to use conventional throat culture or to back up negative RADTs with a culture.

3. Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis as they reflect past but not current events; strong, high).

Who to Test

4. Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers; strong, high).

5. Diagnostic studies for GAS pharyngitis are not indicated for children <3 years old because acute rheumatic fever is rare in children <3 years old and the incidence of streptococcal pharyngitis and the classic presentation of streptococcal pharyngitis are uncommon in this age group. Selected children <3 years old who have other risk factors, such as an older sibling with GAS infection, may be considered for testing (strong, moderate). 6. Follow-up posttreatment throat cultures or RADT are not recommended routinely but may be considered in special circumstances (strong, high). 7. Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended (strong, moderate).

Treatment

8. Patients with acute GAS pharyngitis should be treated with an appropriate antibiotic at an appropriate dose for a duration likely to eradicate the organism from the pharynx (usually 10 days). Based on their narrow spectrum of activity, infrequency of adverse reactions, and modest cost, penicillin or amoxicillin is the recommended drug of choice for those non-allergic to these agents (strong, high).

9. Treatment of GAS pharyngitis in penicillin-allergic individuals should include a first generation cephalosporin (for those not anaphylactically sensitive) for 10 days, clindamycin or clarithromycin for 10 days, or azithromycin for 5 days (strong, moderate).

Adjunctive Therapy

10. Adjunctive therapy may be useful in the management of GAS pharyngitis.
i. If warranted, use of an analgesic/antipyretic agent such as acetaminophen or an NSAID for treatment of moderate to severe symptoms or control of high fever associated with GAS pharyngitis should be considered as an adjunct to an appropriate antibiotic (strong, high).

ii. Aspirin should be avoided in children (strong, moderate).

iii. Corticosteroids are not recommended (weak, moderate).

Recurrent Episodes

11. We recommend that clinicians caring for patients with recurrent episodes of pharyngitis associated with laboratory evidence of GAS pharyngitis consider that they may be experiencing >1 episode of bona fide streptococcal pharyngitis at close intervals, but they should also be alert to the possibility that the patient may actually be a chronic pharyngeal GAS carrier who is experiencing repeated viral infections (strong, moderate).

12. We recommend that GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications (eg, acute rheumatic fever; strong, moderate).

13. We do not recommend tonsillectomy solely to reduce the frequency of GAS pharyngitis (strong, high).

[Clinic’s of Infectious Disease, September 9, 2012]

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