Pharyngitis

Question 1

How should diagnosis of GAS pharmyngitis be established?

Answer 1

1. swabbing the throat and testing for GAS pharyngitis by rapid antigen detection test and or culture should be performed.
2. In children and adolescents, negative RADT should be backed up by a throat culture. Positive RAFT do not necessitate a back up culture because they are highly specific

2. Routine use of back-up throat cultures for those with a negative RADT is not necessary for adults in usual circumstances, because of the low incidence of GAS pharyngitis in adults and because the risk of subsequent acute rheumatic fever is generally exceptionally low in adults with acute pharyngitis (strong, moderate). Physicians who wish to ensure they are achieving maximal sensitivity in diagnosis may continue to use conventional throat culture or to back up negative RADTs with a culture.

 3. Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis as they reflect past but not current events; strong, high).

Question 2

Who should not get testing done for GAS pharyngitis?

Answer 2

4. Testing for GAS pharyngitis usually is not recommended for children or adults with acute pharyngitis with clinical and epidemiological features that strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness, and oral ulcers; strong, high).
5. Children <3
6. household contacts
7. follow -up posttreatment throat cultures or RADT are not recommended routinely but may be considered in special circumstances

Question 3

What are treatment recommendations for patients with diagnosis of GAS pharyngitis?

Answer 3

1. Penicillin or Amox
2. If allergic - cephalosporin (if non-anaphylactic), clindamycin, or clarithromycin for 10 days, or azithromycin for 5 days.

Question 4

Should adjunctive therapy with:
1. NSAIDS,
2. Acetaminophen
3. Aspirin
4. Corticosteroids

Be given?

Answer 4

1. NSAIDS and acetaminophen - Yes
2. Aspirin - not in kids (Reyes syndrome)
3. Steroids - not recommended typically.

Question 5

Is the patient with frequent recurrent episodes of apparent GAS pharngitis likely to be a chroinc pharyngeal carrier of GAS?

Answer 5

1. It is possible patients with multiple lab evidence of GAS may be having real GAS Pharyngitis infections, but they may also be a chronic carrier of GAS and having viral infections
2. We recommend that GAS carriers do not ordinarily justify efforts to identify them nor do they generally require antimicrobial therapy because GAS carriers are unlikely to spread GAS pharyngitis to their close contacts and are at little or no risk for developing suppurative or nonsuppurative complications (eg, acute rheumatic fever; strong, moderate).
3. We do not recommend tonsillectomy solely to reduce the frequency of GAS pharyngitis (strong, high).

Question 6

Why is accurate diagnosis of strep important?

Answer 6

Accurate diagnosis of streptococcal pharyngitis followed by appropriate antimicrobial therapy is important for the prevention of acute rheumatic fever; for the prevention of suppurative complications (eg, peritonsillar abscess, cervical lymphadenitis, mastoiditis, and, possibly, other invasive infections); to improve clinical symptoms and signs; for the rapid decrease in contagiousness; for the reduction in transmission of GAS to family members, classmates, and other close contacts of the patient [11]; to allow for the rapid resumption of usual activities; and for the minimization of potential adverse effects of inappropriate antimicrobial therapy.

Question 7

What are the common bacterial causes of acute pharyngitis?

Answer 7

Question 8

What are common Viral causes of acute pharyngitis?

Answer 8

Question 9

What ages do GAS typically happen at?

Answer 9

5-15 years old and usually in the winter and early spring.

Question 10

How to patients with GAS pharyngitis present?

Answer 10

• Suddent onset of sore throat
• age 5-15
• fever
• headache
• Nausea, Vomiting abdominal pain
• Tonsillopharngeal inflammation
• patchy exudates
• palatal petechiae
• antioror cervical adenitis
• Winter and early spring presentation
• History of exposure to stre pharyngitis
• scarlatiniform rash

Patients with GAS pharyngitis commonly present with sore throat (generally of sudden onset), pain on swallowing, and fever.

Headache, nausea, vomiting, and abdominal pain may also be present, especially in children. On examination, patients have tonsillopharyngeal erythema, with or without exudates, often with tender, enlarged anterior cervical lymph nodes (lymphadenitis). Other findings may include a beefy, red, swollen uvula; petechiae on the palate; excoriated nares (especially in infants); and a scarlatiniform rash

Question 11

What are common symptoms of viral pharyngitis?

Answer 11

• conjunctivity
• coryza
• cough
• diarrhea
• hoarseness
• ulcerative stomatitis
• viral exanthema

Question 12

What virus is responsible for mono pharngitis?

Answer 12

Epstein-Barr

Question 13

What is a likely bacterial cause of pharyngitis that is not GAS amongst college students and adults?

Answer 13

Group C strep

In addition to endemic pharyngitis, GCS can cause epidemic food-borne pharyngitis after ingestion of contaminated products, such as unpasteurized cow’s milk. Family and school outbreaks of GCS pharyngitis have also been described.

Question 14

What is the gold standard test for documentation of GAS?

Answer 14

Throat swab! If performed correctly, culture of a single throat swab on a blood agar plate is 90%–95% sensitive for detection of GAS pharyngitis

Several variables affect the accuracy of throat culture results. For example, the manner in which the swab is obtained has an important impact on the yield of streptococci [37–40]. Throat swab specimens should be obtained from the surface of either tonsils (or tonsillar fossae) and the posterior pharyngeal wall. false-negative results may be obtained if the patient has received an antibiotic shortly before the throat swab is obtained.

Question 15

Talk about RADT!

Answer 15

RADTs currently available are highly specific (approximately 95%) when compared with blood agar plate cultures [38, 43, 44]. False-positive test results are highly unusual, and therefore therapeutic decisions can be made with confidence on the basis of a positive test result [43–45]. Unfortunately, the sensitivity of most of these tests is 70%–90%, compared with blood agar plate culture [43, 44].

Neither conventional throat culture nor RADTs accurately differentiate acutely infected persons from asymptomatic streptococcal carriers with intercurrent viral pharyngitis. Nevertheless, they allow physicians to withhold antibiotics from the great majority of patients with sore throats for whom results of culture or RADT are negative

Question 16

What are symptoms of acute rheumatic fever (Scarlet fever)?

Answer 16

• Joint pain (ankles, knees, hips, elbows, or shoulders
• Fever
• stomach pain, fatigue
• 1 in 10 will get a skin rash
• Abnormal movements (sydenham’s chorea)

Question 17

How long is treatment for GAS for most medications? Azithromycin?

Answer 17

10 days
5 days for azith

Question 18

Why are penicillins considered first line in GAS?

Answer 18

Penicillin, however, remains the treatment of choice because of its proven efficacy and safety, its narrow spectrum, and its low cost [51, 52, 86, 87]. Penicillin-resistant GAS has never been documented.

Question 19

What are possible reasons for repeat positive cultures of GAS?

Answer 19

noncompliance with the prescribed antibiotics; a new GAS pharyngeal infection acquired from family contacts, classroom contacts, or other community contacts; or chronic GAS carriage with intercurrent viral infections [114–116]. A second episode of pharyngitis caused by the original infecting strain of GAS cannot be ruled out but is less common [114].

Question 20

What to do if you suspect a “ping-pong” spread of GAS among family members?

Answer 20

it may be helpful to obtain throat swabs from all family contacts simultaneously and to treat those for whom culture or RADT results are positive.

Question 21

When should tonsillectomies be considered?

Answer 21

Tonsillectomy may be considered in the rare patient whose symptomatic episodes do not diminish in frequency over time and for whom no alternative explanation for recurrent GAS pharyngitis is evident. However, tonsillectomy has been demonstrated to be beneficial only for a relatively small group of these patients, and any benefit can be expected to be relatively short-lived

Question 22

What is chronic GAS carriage?

Answer 22

Chronic carriage refers to asymptomatic colonization or the persistent presence of GAS in the oropharynx in the absence of symptoms or host immune response.

Question 23

What do you do if you have:
1. Positive RADT?
2. Negative RADT?

Answer 23

1. Positive - Treat - No repeat culture needed
2. Negative - backed by throat culture - especially those 5-15 years

Following a negative rapid antigen detection test in children, negative tests should be backed by throat culture; in adolescents, consider backup throat. This is done in these two groups due to the risk of complications. In adults, backup throat culture is not needed, except in certain at risk groups (immunocompromised, patients with a history of or live in an area where rheumatic fever us present, etc.). Use the modified Centor Score to assess for likelihood of Streptococcal infection.

Question 24

Describe the modified centre score

Answer 24

Question 25

What is the main reason for prescribing antibiotics in GAS pharyngitis?

Answer 25

You also want to prevent complications. Infections that spread beyond the throat (otitis media, peritonsillar cellulitis or abscess, sinusitis, meningitis, bacteremia, and necrotizing fasciitis)are called suppurative complications. You also want to prevent nonsuppurative complications of GABS pharyngitis such as acute rheumatic fever, poststreptococcal glomerulonephritis, and reactive arthritis.

Question 26

List some reasonable supportive measures for GAS?

Answer 26

Acetaminophen and NSAIDs may reduce pain. Benzydamine oral rinse or mouth spray may reduce pain and improve symptoms. Other supportive measures without conclusive evidence include: warm salt water gargles; throat lozenges or sugarless hard candy; soft foods or cold thick liquids (such as ice cream, nectars, pudding); humidifying the environment; topical analgesics (such as nonprescription throat sprays) and anesthetics (such as viscous lidocaine 2%). Lidocaine should probably be used cautiously with children and not at all in children who have problems swallowing.

Question 27

When can patients return to work or school?

Answer 27

With antibiotics most patients can return to work or school after completing one full day of treatment, assuming they do not have a fever and are otherwise well. Fever and other symptoms should resolve within one to three days of starting antibiotics.

Question 28

What are the antibiotics for individuals without penicillin allergy for GAS treatment, dose and duration of therapy?

Answer 28

Question 29

What is treatment for patients with non-type 1 pencillin allergy?

Answer 29

Question 30

What are treatment choices for GAS for folks with Type 1 (anaphylactic reaction) allergy to penicillin?

Answer 30

Question 31

Which patients should a test of cure be done in?

Answer 31

It is recommended in those with risk for complications (previous history of rheumatic fever), recurrent infection, acquired the infection during an outbreak of acute rheumatic fever or poststreptococcal glomerulonephritis or spreading infection to others.

Question 32

How can one prevent GABS?

Answer 32

You can prevent GABS pharyngitis by having good hand hygiene.32 Especially after coughing or sneezing and before preparing foods or eating.

Question 33

When is treatment of asymptomatic persons exposed to GABS pharyngitis done?

Answer 33

Treatment of asymptomatic persons who have been exposed to a patient with GABS pharyngitis is not routinely done. The exceptions are the ones we have previously mentioned as being more complicated. This includes patients with a history of acute rheumatic fever, during outbreaks of acute rheumatic fever and/or poststreptococcal glomerulonephritis, or when GAS infections are recurring in households or other close-contact settings.

Question 34

When might we treat chronic GAS carriers?

Answer 34

Antibiotic treatment is not routinely recommended for chronic carriers.31 Treating carriers during outbreaks of acute rheumatic fever and/or poststreptococcal glomerulonephritis or when GASS infections are recurring in households or other close-contact settings may be warranted.