Medicine:Streptococcal pharyngitis

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Streptococcal pharyngitis
Other namesStreptococcal sore throat, strep throat
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, enlarged 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 streptococcal sore throat (strep throat), is pharyngitis (an infection of the pharynx, the back of the throat) caused by Streptococcus pyogenes, a gram-positive, group A streptococcus.[9][10] Common symptoms include fever, sore throat, red tonsils, and enlarged lymph nodes in the front of the neck. A headache and nausea or vomiting may also occur.[11] 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][11]

Strep throat is spread by respiratory droplets from an infected person, spread by talking, coughing or sneezing, or by touching something that has droplets on it and then touching the mouth, nose, or eyes. It may be spread directly through touching infected sores. It may also be spread by contact with skin infected with group A strep. The diagnosis is made based on the results of a rapid antigen detection test or throat culture. Some people may carry the bacteria without symptoms.[11]

Prevention is by frequent hand washing, and not sharing eating utensils.[11] There is no vaccine for the disease.[1] Treatment with antibiotics is only recommended in those with a confirmed diagnosis.[12] Those infected should stay away from other people until fever is gone and for at least 12 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.[2] It is the cause of 15–40% of sore throats among children[7][13] and 5–15% among adults.[8] Cases are more common in late winter and early spring.[13] Potential complications include rheumatic fever and peritonsillar abscess.[1][2]

Signs and symptoms

The typical signs and symptoms of streptococcal pharyngitis are a sore throat, fever of greater than 38 °C (100 °F), tonsillar exudates (pus on the tonsils), and large cervical lymph nodes.[13]

Other symptoms include: headache, nausea and vomiting, abdominal pain,[14] muscle pain,[15] or a scarlatiniform rash or palatal petechiae, the latter being an uncommon but highly specific finding.[13]

Symptoms typically begin one to three days after exposure and last seven to ten days.[3][13]

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.[13]

  • A set of large tonsils in the back of the throat, covered in white exudate.
    This is 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).[16] Humans are the primary natural reservoir for group A streptococcus.[17] Other bacteria such as non–group A β-hemolytic streptococci and fusobacterium may also cause pharyngitis.[13][15] 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.[15][18] Dried bacteria in dust are not infectious, although moist bacteria on toothbrushes or similar items can persist for up to fifteen days.[15] Contaminated food can result in outbreaks, but this is rare.[15] 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".[19]

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.[20] The modified Centor criteria are a set of five criteria; the total score indicates the probability of a streptococcal infection.[13]

One point is given for each of the criteria:[13]

  • 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.[13]

The Infectious Disease Society of America recommends against routine antibiotic 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 a child has a sibling with the disease.[8]

Laboratory testing

A throat culture is the gold standard[21] for the diagnosis of streptococcal pharyngitis, with a sensitivity of 90–95%.[13] A rapid strep test (also called rapid antigen detection testing or RADT) may also be used. While the rapid strep test is quicker, it has a lower sensitivity (70%) and statistically equal specificity (98%) as a throat culture.[13] In areas of the world where rheumatic fever is uncommon, a negative rapid strep test is sufficient to rule out the disease.[22]

A positive throat culture or RADT in association with symptoms establishes a positive diagnosis in those in which the diagnosis is in doubt.[23] In adults, a negative RADT is sufficient to rule out the diagnosis. However, in children a throat culture is recommended to confirm the result.[8] Asymptomatic individuals should not be routinely tested with a throat culture or RADT because a certain percentage of the population persistently "carries" the streptococcal bacteria in their throat without any harmful results.[23]

Differential diagnosis

As the symptoms of streptococcal pharyngitis overlap with other conditions, it can be difficult to make the diagnosis clinically.[13] 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.[13] 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.[13] Treatment with antibiotics shortens the duration of the acute illness by about 16 hours.[13] The primary reason for treatment with antibiotics is to reduce the risk of complications such as rheumatic fever and retropharyngeal abscesses.[13] Antibiotics prevent acute rheumatic fever if given within 9 days of the onset of symptoms.[16]

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,[16][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.[16]

Antibiotics

The antibiotic of choice in the United States for streptococcal pharyngitis is penicillin V, due to safety, cost, and effectiveness.[13] 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.[16]

Appropriate antibiotics decrease the average 3–5 day duration of symptoms by about one day, and also reduce contagiousness.[23] They are primarily prescribed to reduce rare complications such as rheumatic fever and peritonsillar abscess.[33] The arguments in favor of antibiotic treatment should be balanced by the consideration of possible side effects,[15] 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.[33][34] Antibiotics are prescribed for strep throat at a higher rate than would be expected from how common it is.[35]

Erythromycin and other macrolides or clindamycin are recommended for people with severe penicillin allergies.[13][8] First-generation cephalosporins may be used in those with less severe allergies[13] and some low-certainty evidence suggest cephalosporins are superior to penicillin.[36][37] These late-generation antibiotics show a similar effect when prescribed for 3–7 days in comparison to the standard ten days of penicillin when used in areas of low rheumatic heart disease.[38] Streptococcal infections may also lead to acute glomerulonephritis; however, the incidence of this side effect is not reduced by the use of antibiotics.[16]

Prognosis

The symptoms of strep throat usually improve within three to five days, irrespective of treatment.[23] Treatment with antibiotics reduces the risk of complications and transmission; children may return to school 24 hours after antibiotics are administered.[13] 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

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.[13] It is the cause of 15–40% of sore throats among children[7][13] and 5–15% in adults.[8] Cases usually occur in late winter and early spring.[13]

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 "Is It Strep Throat?". CDC. October 19, 2015. https://www.cdc.gov/Features/StrepThroat/. 
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 Oxford textbook of medicine infection. Oxford: Oxford University Press. 2012. pp. 280–281. ISBN 9780191631733. https://books.google.com/books?id=qkLibW2ZikYC&pg=PA280. 
  3. ↑ 3.0 3.1 3.2 3.3 Goroll, Allan H.; Mulley, Albert G. Jr. (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. https://books.google.com/books?id=bIZvJPcSEXMC&pg=PA1408. 
  4. ↑ 4.0 4.1 "Strep throat - Symptoms and causes" (in en). https://www.mayoclinic.org/diseases-conditions/strep-throat/symptoms-causes/syc-20350338. 
  5. ↑ 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. ↑ 6.0 6.1 Weber, R (March 2014). "Pharyngitis". Primary Care 41 (1): 91–8. doi:10.1016/j.pop.2013.10.010. PMID 24439883. 
  7. ↑ 7.0 7.1 7.2 7.3 "Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis". Pediatrics 126 (3): e557–64. September 2010. doi:10.1542/peds.2009-2648. PMID 20696723. 
  8. ↑ 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. ↑ "ICD-11 for Mortality and Morbidity Statistics". https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f1642172022. 
  10. ↑ "Pharyngitis (Strep Throat): Information For Clinicians | CDC" (in en-us). 19 December 2022. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html. 
  11. ↑ 11.0 11.1 11.2 11.3 "Is your sore throat strep?" (in en-us). 2 November 2022. https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html. 
  12. ↑ 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. 
  13. ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 13.12 13.13 13.14 13.15 13.16 13.17 13.18 13.19 13.20 13.21 13.22 13.23 Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067. http://www.aafp.org/afp/2009/0301/p383.html. 
  14. ↑ 14.0 14.1 "Management of group A beta-hemolytic streptococcal pharyngotonsillitis in children". J Fam Pract 55 (12): S1–11; quiz S12. December 2006. PMID 17137534. 
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 "Management of Group A beta-hemolytic streptococcal pharyngitis". Am Fam Physician 63 (8): 1557–64. April 2001. PMID 11327431. http://www.aafp.org/afp/20010415/1557.html. 
  16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 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. 
  17. ↑ "Group A Strep" (in en-us). U. S. Department of Health & Human Services. 2019-04-19. https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html. 
  18. ↑ "Predictors for spread of clinical group A streptococcal tonsillitis within the household". Scand J Prim Health Care 22 (4): 239–43. 2004. doi:10.1080/02813430410006729. PMID 15765640. 
  19. ↑ Textbook of family medicine (8th ed.). Philadelphia, PA.: Elsevier Saunders. 2011. pp. 331. ISBN 9781437711608. https://books.google.com/books?id=t0Mh0yOH5EsC&pg=PA331. 
  20. ↑ 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. PMID 25487666. 
  21. ↑ Smith, Ellen Reid; Kahan, Scott; Miller, Redonda G. (2008). In A Page Signs & Symptoms. In a Page Series. Hagerstown, Maryland: Lippincott Williams & Wilkins. pp. 312. ISBN 978-0-7817-7043-9. 
  22. ↑ 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. 
  23. ↑ 23.0 23.1 23.2 23.3 "Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America". Clin. Infect. Dis. 35 (2): 113–25. July 2002. doi:10.1086/340949. PMID 12087516. https://academic.oup.com/cid/article-pdf/35/2/113/13141808/35-2-113.pdf. 
  24. ↑ Ebell MH (2004). "Epstein-Barr virus infectious mononucleosis". Am Fam Physician 70 (7): 1279–87. PMID 15508538. http://www.aafp.org/afp/20041001/1279.html. 
  25. ↑ "Cost-effective workup for tonsillitis. Testing, treatment, and potential complications". Postgrad Med 113 (3): 115–8, 121. March 2003. doi:10.3810/pgm.2003.03.1391. PMID 12647478. 
  26. ↑ "Adenotonsillectomy for upper respiratory infections: evidence based?". Archives of Disease in Childhood 90 (1): 19–25. January 2005. doi:10.1136/adc.2003.047530. PMID 15613505. 
  27. ↑ Burton, MJ; Glasziou, PP; Chong, LY; Venekamp, RP (19 November 2014). "Tonsillectomy or adenotonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis.". The Cochrane Database of Systematic Reviews 2014 (11): CD001802. doi:10.1002/14651858.CD001802.pub3. PMID 25407135. PMC 7075105. https://pure.bond.edu.au/ws/files/32844113/Tonsillectomy_or_adenotonsillectomy_versus_non_surgical_treatment_for_chronic.pdf. 
  28. ↑ 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" (in en). Pediatrics 139 (2): e20163490. doi:10.1542/peds.2016-3490. ISSN 0031-4005. PMID 28096515. PMC 5260157. http://pediatrics.aappublications.org/content/early/2017/01/15/peds.2016-3490?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3A+No+local+token. 
  29. ↑ "How effective are treatments other than antibiotics for acute sore throat?". Br J Gen Pract 50 (459): 817–20. October 2000. PMID 11127175. 
  30. ↑ "Generic Name: Lidocaine Viscous (Xylocaine Viscous) side effects, medical uses, and drug interactions". MedicineNet.com. http://www.medicinenet.com/lidocaine_viscous/article.htm. 
  31. ↑ 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. 
  32. ↑ "The infections of the upper respiratory tract in children". Int J Immunopathol Pharmacol 23 (1 Suppl): 16–9. 2010. doi:10.1177/03946320100230S105. PMID 20152073. 
  33. ↑ 33.0 33.1 "Principles of appropriate antibiotic use for acute pharyngitis in adults". Ann Intern Med 134 (6): 506–8. March 2001. doi:10.7326/0003-4819-134-6-200103200-00018. PMID 11255529. [needs update?]
  34. ↑ 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. 
  35. ↑ "Antibiotic treatment of children with sore throat". J Am Med Assoc 294 (18): 2315–22. November 2005. doi:10.1001/jama.294.18.2315. PMID 16278359. 
  36. ↑ 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. 
  37. ↑ Hedin, Katarina; Thorning, Sarah; van Driel, Mieke L. (2023-11-15). "Different antibiotic treatments for group A streptococcal pharyngitis". The Cochrane Database of Systematic Reviews 2023 (11): CD004406. doi:10.1002/14651858.CD004406.pub6. ISSN 1469-493X. PMID 37965935. 
  38. ↑ 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. 
  39. ↑ 39.0 39.1 "UpToDate Inc.". http://www.utdol.com/online/content/topic.do?topicKey=upp_resp/4610. 
  40. ↑ "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. July 1989. doi:10.1056/NEJM198907063210101. PMID 2659990. 
  41. ↑ "Evaluation of poststreptococcal illness". Am Fam Physician 71 (10): 1949–54. May 2005. PMID 15926411. 
  42. ↑ "PANDAS/PANS in childhood: Controversies and evidence". Paediatr Child Health 24 (2): 85–91. May 2019. doi:10.1093/pch/pxy145. PMID 30996598. 
  43. ↑ "Treatment of PANDAS and PANS: a systematic review". Neurosci Biobehav Rev 86: 51–65. March 2018. doi:10.1016/j.neubiorev.2018.01.001. PMID 29309797. 
  44. ↑ "What every psychiatrist should know about PANDAS: a review". Clin Pract Epidemiol Ment Health 4 (1): 13. 2008. doi:10.1186/1745-0179-4-13. PMID 18495013. 

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