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Streptococcal pharyngitis

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Streptococcal pharyngitis
Other names: Streptococcal tonsillitis, streptococcal sore throat, strep
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 a 16-year-old.
SpecialtyInfectious disease
SymptomsFever, sore throat, large lymph nodes[1]
Usual onset1–3 days after exposure[2][3]
Duration7–10 days[2][3]
CausesGroup A streptococcus[1]
Risk factorsSharing drinks or eating utensils[4]
Diagnostic methodThroat culture, strep test[1]
Differential diagnosisEpiglottitis, infectious mononucleosis, Ludwig's angina, peritonsillar abscess, retropharyngeal abscess, viral pharyngitis[5]
PreventionHandwashing,[1] covering coughs[4]
TreatmentParacetamol (acetaminophen), NSAIDs, antibiotics[1][6]
Frequency5 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]

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

Modified Centor score
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

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