Streptococcal pharyngitis
Streptococcal pharyngitis | |
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Other names: Streptococcal tonsillitis, streptococcal sore throat, strep | |
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] |
Risk factors | Sharing drinks or eating utensils[4] |
Diagnostic method | Throat culture, strep test[1] |
Differential diagnosis | Epiglottitis, infectious mononucleosis, Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, viral pharyngitis[5] |
Prevention | Handwashing,[1] covering coughs[4] |
Treatment | Paracetamol (acetaminophen), NSAIDs, antibiotics[1][6] |
Frequency | 5 to 40% of sore throats[7][8] |
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] Diagnosis is based on a rapid strep test or throat culture in those who have symptoms.[9][10]
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.[9] 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.[6]
Strep throat is a common bacterial infection in children with an estimated 288 million cases occuring in children age five to 14 years a year.[11] It is the cause of 15–40% of sore throats among children[7][12] and 5–15% among adults.[8] Cases are more common in late winter and early spring.[12] Potential complications include rheumatic fever and peritonsillar abscess.[1]
Signs and symptoms
The typical signs and symptoms of strep throat are a sore throat, fever, pus on the tonsils), and large neck glands.[1] It tends to make swallowing painful.[1]
Other symptoms include: headache, nausea and vomiting, abdominal pain,[1] [13] muscle pain.[14] or palatal petechiae; an uncommon but highly specific finding.[12] When accompanied by a scarlet rash it as referred to as scarlet fever.[1]
Symptoms typically begin one to three days after exposure and last seven to ten days.[3][12]
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.[8]
-
Mouth wide open showing the throat
A throat infection which on culture tested positive for group A streptococcus. Note the large tonsils with white exudate. -
Mouth wide open showing the throat
Note the petechiae, or small red spots, on the soft palate. This is an uncommon but highly specific finding in streptococcal pharyngitis.[12] -
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 an 8-year-old.
Cause
Strep throat is caused by group A β-hemolytic Streptococcus (GAS or S. pyogenes).[15] Other bacteria such as non–group A β-hemolytic streptococci and fusobacterium may also cause pharyngitis.[12][14] 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.[14][16] Dried bacteria in dust are not infectious, although moist bacteria on toothbrushes or similar items can persist for up to fifteen days.[14] Contaminated food can result in outbreaks, but this is rare.[14] Of children with no signs or symptoms, 12% carry GAS in their pharynx,[7] and, after treatment, approximately 15% of those remain positive, and are true "carriers".[17]
Diagnosis
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.[18] The modified Centor criteria are a set of five criteria; the total score indicates the probability of a streptococcal infection.[12]
One point is given for each of the criteria:[12]
- 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 indicate 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.[12]
The Infectious Disease Society of America recommends against empirical treatment and considers antibiotics only appropriate when given after a positive test.[8] Testing is not needed in children under three as both group A strep and rheumatic fever are rare, unless the child has a sibling with the disease.[8][19] Also, those with clear viral symptoms, such as cough, runny nose, hoarseness, and red eyes, do not need further testing.[19]
Laboratory testing
A throat culture is the gold standard for the diagnosis of streptococcal pharyngitis, with a sensitivity of 90–95%.[12][20] A rapid strep test, also called a rapid antigen detection testing (RADT) or nucleic acid detection test, may also be used.[10] While the rapid strep test is quicker, it has a lower sensitivity (85 to 92%), though equal specificity (98%) as a throat culture.[12][10]
A positive throat culture or RADT in association with symptoms establishes a positive diagnosis in those in which the diagnosis is in doubt.[21] In areas of the world where rheumatic fever is uncommon, a negative rapid strep test is sufficient to rule out the disease in adults; though the CDC still recommends culturing in children.[22][23][8]
Asymptomatic individuals should not be routinely tested with a throat culture or RADT because some of the population persistently "carries" the streptococcal bacteria in their throat without any harmful results.[21]
Differential diagnosis
As the symptoms of streptococcal pharyngitis overlap with other conditions, it can be difficult to make the diagnosis clinically.[12] 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.[12] The presence of marked lymph node enlargement along with sore throat, fever, and tonsillar enlargement may also occur in infectious mononucleosis.[24] Other conditions that may present similarly include epiglottitis, Kawasaki disease, acute retroviral syndrome, Lemierre's syndrome, Ludwig's angina, peritonsillar abscess, and retropharyngeal abscess.[5]
Prevention
Tonsillectomy may be a reasonable preventive measure in those with frequent throat infections (more than three a year).[25] However, the benefits are small and episodes typically lessen in time regardless of measures taken.[26][27][28] 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.[8] Treating people who have been exposed but who are without symptoms is not recommended.[8] Treating people who are carriers of GAS is not recommended as the risk of spread and complications is low.[8]
Treatment
Untreated streptococcal pharyngitis usually resolves within a few days.[12] Treatment with antibiotics shortens the duration of the acute illness by about 16 hours.[12] The primary reason for treatment with antibiotics is to reduce the risk of complications such as rheumatic fever and retropharyngeal abscesses.[12] Antibiotics prevent acute rheumatic fever if given within 9 days of the onset of symptoms.[15]
Pain medication
Pain medication such as NSAIDs and paracetamol (acetaminophen) helps in the management of pain associated with strep throat.[29] Viscous lidocaine may also be useful.[30] While steroids may help with the pain,[15][31] they are not routinely recommended.[8] Aspirin may be used in adults but is not recommended in children due to the risk of Reye syndrome.[15]
Antibiotics
The antibiotic of choice in the United States for streptococcal pharyngitis is penicillin V, due to safety, cost, and effectiveness.[12] Amoxicillin is preferred in Europe.[32] In India, where the risk of rheumatic fever is higher, intramuscular benzathine penicillin G is the first choice for treatment.[15] In areas with a low risk of rheumatic fever 5 days of penicillin V or amoxicillin is sufficient while in regions with were it is common, 10 days are used.[33][34]
Appropriate antibiotics decrease the average 3–5 day duration of symptoms by about one day, and also reduce contagiousness.[21] They are primarily prescribed to reduce rare complications such as rheumatic fever and peritonsillar abscess.[35] The arguments in favor of antibiotic treatment should be balanced by the consideration of possible side effects,[14] 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.[35][36] Antibiotics are prescribed for strep throat at a higher rate than would be expected from how common it is.[37]
Erythromycin and other macrolides or clindamycin are recommended for people with severe penicillin allergies.[12][8] First-generation cephalosporins may be used in those with less severe allergies[12] and some evidence supports cephalosporins as superior to penicillin.[38][39] These late-generation antibiotics show a similar effect when prescribed for 3-7 days in comparison to the standard 10-days of penicillin when used in areas of low rheumatic heart disease.[40] Streptococcal infections may also lead to acute glomerulonephritis; while the risk of this side effect has often been stated to not be reduced by the use of antibiotics, others have stated that antibiotics may decrease the risk.[15][41]
Prognosis
The symptoms of strep throat usually improve within three to five days, irrespective of treatment.[21] Treatment with antibiotics reduces the risk of complications and transmission; children may return to school 24 hours after antibiotics are administered.[12] The risk of complications in adults is low.[8] 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.[8]
Complications arising from streptococcal throat infections include:
The economic cost of the disease in the United States in children is approximately $350 million annually.[8]
Epidemiology
Pharyngitis, the broader category into which Streptococcal pharyngitis falls, is diagnosed in 11 million people annually in the United States.[12] It is the cause of 15–40% of sore throats among children[7][12] and 5–15% in adults.[8] Cases usually occur in late winter and early spring.[12]
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 "Is your sore throat strep?". Centers for Disease Control and Prevention. 2 November 2022. Archived from the original on 3 December 2022. Retrieved 5 December 2022.
- ↑ 2.0 2.1 2.2 2.3 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.
- ↑ 3.0 3.1 3.2 3.3 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.
- ↑ 4.0 4.1 "Strep throat - Symptoms and causes". Mayo Clinic. Archived from the original on 4 July 2021. Retrieved 24 January 2020.
- ↑ 5.0 5.1 Gottlieb, M; Long, B; Koyfman, A (May 2018). "Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics". The Journal of Emergency Medicine. 54 (5): 619–629. doi:10.1016/j.jemermed.2018.01.031. PMID 29523424.
- ↑ 6.0 6.1 Weber, R (March 2014). "Pharyngitis". Primary Care. 41 (1): 91–8. doi:10.1016/j.pop.2013.10.010. PMC 7119355. PMID 24439883.
- ↑ 7.0 7.1 7.2 7.3 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.
- ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 8.12 8.13 8.14 8.15 8.16 8.17 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.
- ↑ 9.0 9.1 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 (6): 425–34. doi:10.7326/M15-1840. PMID 26785402.
- ↑ 10.0 10.1 10.2 Ton, Joey (28 October 2019). "#246 Just wait a minute: Point-of-care testing for Group A Streptococcal pharyngitis". CFPCLearn. Archived from the original on 25 March 2023. Retrieved 15 June 2023.
- ↑ Miller, Kate M.; Carapetis, Jonathan R.; Beneden, Chris A. Van; Cadarette, Daniel; Daw, Jessica N.; Moore, Hannah C.; Bloom, David E.; Cannon, Jeffrey W. (1 June 2022). "The global burden of sore throat and group A Streptococcus pharyngitis: A systematic review and meta-analysis". eClinicalMedicine. 48. doi:10.1016/j.eclinm.2022.101458. ISSN 2589-5370. Archived from the original on 3 December 2022. Retrieved 5 December 2022.
- ↑ 12.00 12.01 12.02 12.03 12.04 12.05 12.06 12.07 12.08 12.09 12.10 12.11 12.12 12.13 12.14 12.15 12.16 12.17 12.18 12.19 12.20 12.21 12.22 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.
- ↑ 13.0 13.1 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.
- ↑ 14.0 14.1 14.2 14.3 14.4 14.5 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.
- ↑ 15.0 15.1 15.2 15.3 15.4 15.5 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.
- ↑ Lindbaek M, Høiby EA, Lermark G, Steinsholt IM, Hjortdahl P (2004). "Predictors for spread of clinical group A streptococcal tonsillitis within the household". Scand J Prim Health Care. 22 (4): 239–43. doi:10.1080/02813430410006729. PMID 15765640.
- ↑ 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.
- ↑ 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 4284164. PMID 25487666.
- ↑ 19.0 19.1 "Pharyngitis (Strep Throat): Information For Clinicians | CDC". www.cdc.gov. 13 July 2023. Archived from the original on 27 October 2020. Retrieved 21 February 2024.
- ↑ 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 978-0-7817-7043-9.
- ↑ 21.0 21.1 21.2 21.3 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" (PDF). Clin. Infect. Dis. 35 (2): 113–25. doi:10.1086/340949. PMID 12087516. Archived from the original on 2020-11-01. Retrieved 2018-04-20.
- ↑ 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.
- ↑ "Is your sore throat strep?". Centers for Disease Control and Prevention. 19 January 2024. Archived from the original on 3 December 2022. Retrieved 21 February 2024.
- ↑ 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.
- ↑ 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.
- ↑ 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 1720065. PMID 15613505.
- ↑ Burton, MJ; Glasziou, PP; Chong, LY; Venekamp, RP (19 November 2014). "Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis" (PDF). The Cochrane Database of Systematic Reviews (11): CD001802. doi:10.1002/14651858.CD001802.pub3. PMID 25407135. Archived (PDF) from the original on 15 May 2021. Retrieved 1 December 2019.
- ↑ 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 5260157. PMID 28096515. Archived from the original on 13 August 2017.
- ↑ 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 1313826. PMID 11127175.
- ↑ "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.
- ↑ 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. Archived from the original on 2021-06-04. Retrieved 2019-12-01.
- ↑ 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.
- ↑ Web Annex. Infographics. In: The WHO AWaRe (Access, Watch, Reserve) antibiotic book (PDF). World Health Organization. 2022. p. 48. Archived (PDF) from the original on 28 January 2023. Retrieved 29 March 2023.
- ↑ Altamimi, S; Khalil, A; Khalaiwi, KA; Milner, RA; Pusic, MV; Al Othman, MA (15 August 2012). "Short-term late-generation antibiotics versus longer term penicillin for acute streptococcal pharyngitis in children". The Cochrane database of systematic reviews (8): CD004872. doi:10.1002/14651858.CD004872.pub3. PMID 22895944.
- ↑ 35.0 35.1 Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR (March 2001). "Principles of appropriate antibiotic use for acute pharyngitis in adults". Ann Intern Med. 134 (6): 506–8. doi:10.7326/0003-4819-134-6-200103200-00018. PMID 11255529.[needs update?]
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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. PMC 6457741. PMID 27614728.
- ↑ Altamimi, Saleh; Khalil, Adli; Khalaiwi, Khalid A; Milner, Ruth A; Pusic, Martin V; Al Othman, Mohammed A (15 August 2012). "Short-term late-generation antibiotics versus longer term penicillin for acute streptococcal pharyngitis in children". Cochrane Database of Systematic Reviews (8): CD004872. doi:10.1002/14651858.CD004872.pub3. PMID 22895944.
- ↑ Sainato, Rebecca J.; Weisse, Martin E. (January 2019). "Poststreptococcal Glomerulonephritis and Antibiotics: A Fresh Look at Old Data". Clinical Pediatrics. 58 (1): 10–12. doi:10.1177/0009922818793345.
- ↑ 42.0 42.1 "UpToDate Inc". Archived from the original on 2008-12-08.
- ↑ 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.
- ↑ 44.0 44.1 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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