This week’s materials:
- Case and discussion by Dr. Wright
- General pediatrics’ outpatient sore throat guideline
- Infectious Disease Society 2012 clinical guidelines
- Powerpoint shared by Dr. Abby Grant
Take-home points for evaluating a possible diagnosis of strep throat:
- Which children with sore throat should we test for strep infection? We can use the Centor criteria to help. Positive criteria include age 3-14, exudate or swelling on tonsils, tender/swollen anterior lymph nodes, temp >38.0, and absence of cough. (See this PedsEM Podcast on strep throat and importance of considering pre-test probability.) We should not test children who have symptoms strongly suggesting a viral infection such as cough, rhinorrhea, hoarseness, or oral ulcers. Presence of either a scarlitiniform rash or palatal petechiae are also predictors of GASP, but not foolproof, so testing is recommended for these symptoms as well. Only test children under 3 who have a known contact or highly concerning exam.
- When should we initiate antibiotics for strep pharyngitis? Contrary to prior practices, we now recommend that all children have a confirmed positive rapid strep or strep culture before being treated with antibiotics. This is due to a larger concern about overuse of antibiotics, and a persistent decline in rates of rheumatic fever.
- What should we use to treat GASP? 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 (reserved for penicillin allergic patients). (I prefer amox for the BID dosing and the slightly higher rate of eradication compared to penicillin, which is probably mostly based on compliance.)
- Should we treat sick contacts without testing? It is no longer recommended to presumptively treat sick contacts – clinical guidelines now recommend that everyone treated have testing that confirms the presence of GAS. (We had an example of this in clinic for a sibling sick contact who had concerning symptoms, but did not test positive, even on culture. That sibling then infected the first one with the virus!)
- How many kids are GAS carriers? There is a fairly high normal carriage rate for Group A streptococcus in children – as high as 15%. This really reinforces we do not test unless we have a higher concern for strep throat.