Pharyngitis

One of the most frequent reasons that parents bring their children to our office is to evaluate a sore throat. The role of the clinician in these cases is to distinguish which children have infection with group A streptococcus (GAS), or “strep throat,” from those with viral infections of the throat. This distinction is important, since antibiotics will not be helpful in treating viral infections of the throat, and other causes of bacterial infection of the throat are extremely rare. On an average day in our office, only about 1/3 of those tested for strep throat will be positive. The following are typical signs and symptoms of streptococcal infections. One or more of these may be present:
 
  • Sore throat or sore neck.
  • Headache.
  • Swollen lymph nodes in the neck.
  • Nausea, abdominal pain, and sometimes vomiting.
  • Confluent red or pink rash which feels rough to the touch, involving the face, trunk, or groin area.
  • In rare cases, excessive drooling, inability to open the mouth, stiff neck, large neck mass, or bulging of the tonsil or surrounding tissues. These might signal abscess formation.
  • Cough and runny nose are not typical symptoms of streptococcal throat infection.
 
Diagnosis
 
Streptococcal pharyngitis is most common in school age children and adolescents, but may occur at any age. It results from contact with respiratory secretions from another infected person. Household pets are not a source of GAS infections in humans. Those children with any combination of the typical signs and symptoms should have their throat swabbed and tested for group A streptococcus. Like most offices, we run a rapid antigen test first. If it is positive for streptococcus, then the presence of GAS is confirmed. If the rapid antigen test is negative, then a 48 hour culture will be done as a back-up test. If both the rapid antigen and blood agar tests are negative, then GAS has been excluded, and viral infection is likely.   
 
Antibiotic Treatment
 
The following are highlights from the treatment guidelines published by the AmericanAcademy of Pediatrics “Red Book” Report of the Committee of Infectious Diseases:
 
  • Antimicrobial therapy should not be given to a child with pharyngitis in the absence of identified group A streptococci, except in the rare instance of other bacterial causes.
  • Penicillin based drugs, including amoxicillin, are the drug of first choice, because resistance of GAS to penicillin has never been documented.
  • Intramuscular penicillin G given in a single dose is appropriate therapy. 
  • Oral cephalosporin antibiotics are an acceptable alternative to penicillin based drugs, especially in those patients with mild penicillin allergy. Up to 15% of patients who are allergic to penicillin will also be allergic to cephalosporin based drugs. 
  • For patients with severe allergy to penicillin the best choice may be erythromycin or other antibiotics in the same family.
  • For those patients with recurrence of streptococcus shortly after completing a course of antibiotics, there is differing opinion about re-treatment.   Since resistance to penicillin has not been documented, one acceptable alternative is to repeat amoxicillin.
 
Please note that the above guidelines are not intended to be used in all situations. The medical provider must use their experience and judgment in each case to decide on the best treatment.

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