Flu vaccines are now available so 'tis the season to be preparing for URIs! As children have returned back to school, we now see the onslaught of the school fomite breeding ground! (We already have our first back-to-school cold at our house this week). One of our big roles as pediatricians when we see children with a sore throat is helping distinguish between viral infections and strep throat (Group A Strep Pharyngitis or GASP). Thanks to our incredibly knowledgeable general pediatrics guru Jeff Wright, we have a brief algorithm to help guide our decisions. *Reminder – you can also review our other general pediatrics outpatient guidelines posted here.
This week's materials: Case and discussion by Dr. Wright and our general pediatrics' outpatient sore throat guideline. Infectious Disease Society 2012 clinical guidelines and an article reviewing performance characteristics of strep testing.
Take-home points for evaluating a possible diagnosis of strep throat:
- We now recommend that all children have a confirmed positive rapid strep or strep culture before being treated with antibiotics. This is due mostly to a larger concern about overuse of antibiotics and a prolonged and persistent decline in rate of rheumatic fever. Do not test children who have symptoms strongly suggesting a viral infection such as cough, rhinorrhea, hoarseness, or oral ulcers. Only test children under 3 who have a known contact or highly concerning exam.
- Treat confirmed strep throat with oral penicillin, amoxicillin, or cephalexin given for 10 days, a single injection of Benzathine G penicillin, or 5 days of oral azithromycin (for penicillin allergic patients).
- Presence of either a scarlitiniform rash or palatal petechiae are strong predictors of GASP, but not foolproof, so testing is recommended.
- We should no longer presumptively treat sick contacts – clinical guidelines now recommend that all people who are treated have testing that confirms the presence of GAS.
- Remember, there is a fairly high normal carriage rate for Group A streptococcus in children – as high as 15%, so we do not test unless we have a higher concern for strep throat. There are also fairly high numbers of recurrence, so it is prudent to retest and retreat, as appropriate.