Diagnosis and Management of Group A Streptococcal Pharyngitis and Associated Complications

Table of Contents

 

Emergency clinicians must recognize group A Streptococcus (GAS) pharyngitis and offer appropriate diagnosis and treatment to promote good antibiotic stewardship. In this issue, you will learn to:

Identify pediatric patients at risk for GAS pharyngitis and associated complications

Recognize the clinical signs and symptoms of GAS pharyngitis and differentiate them from viral and bacterial infections

Order rapid antigen detection testing or throat culture appropriately

Prescribe appropriate antibiotics for patients who need them, including alternatives for patients with beta-lactam allergies

Identify patients who may be discharged home, and those who need to be admitted for further management or observation

Recognize and manage various complications of GAS pharyngitis, such as peritonsillar abscess and acute rheumatic fever

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Modified/McIsaac Centor Criteria Clinical Scoring System
   2. Rapid Antigen Detection Testing/Throat Culture
   3. Antistreptococcal Antibody Titers
10. Treatment
    1. Treatment With Antibiotics
    2. Adjunctive Therapies
11. Special Circumstances
    1. Complications
       1. Suppurative Complications
          • Peritonsillar Abscess
          • Retropharyngeal Abscess
          • Cervical Lymphadenitis
          • Bacteremia
          • Necrotizing Faciitis
          • Streptococcal Toxic Shock Syndrome
       2. Nonsuppurative Complications
          • Acute Rheumatic Fever and Rheumatic Heart Disease
          • Poststreptococcal Glomerulonephritis
    2. GAS Carriers
12. Controversies and Cutting Edge
    1. Tonsillectomy
    2. Molecular-based Testing
    3. Vaccines
13. Disposition
14. Summary
15. Risk Management Pitfalls in the Management of Patients With Group A Streptococcal Pharyngitis
16. Time- and Cost-Effective Strategies
17. Case Conclusions
18. Clinical Pathway for Management of Possible GAS Pharyngitis or Suppurative Complications in the Emergency Department
19. Tables and Figures
    1. Table 1. Modified-McIsaac Centor Criteria
    2. Table 2. Antibiotic Therapy Options for RADT- or Throat Culture-Positive GAS Pharyngitis
    3. Table 3. Adjunctive Therapy for GAS Pharyngitis
    4. Table 4. Jones Criteria for Acute Rheumatic Fever
    5. Table 5. Circumstances Requiring Treatment of GAS Carriers
    6. Table 6. Antibiotic Regimens for the Eradication of GAS Carriage
    7. Figure 1. Palatal Petechiae
    8. Figure 2. “Sandpapery” Scarlatiniform Rash
    9. Figure 3. Peritonsillar Abscess
20. References

Abstract

Although group A Streptococcus (GAS) pharyngitis is the most common cause of bacterial pharyngitis in children and adolescents, many viral and bacterial infections mimic the symptoms of GAS pharyngitis. Emergency clinicians must recognize the symptomatology of GAS pharyngitis and use appropriate means of diagnosis and treatment to promote good antibiotic stewardship. This issue reviews the signs and symptoms of GAS pharyngitis, as well as associated complications, and provides recommendations for appropriate treatment that focuses on reducing the severity and duration of symptoms, reducing the incidence of nonsuppurative complications, and reducing transmission.

Case Presentation

A previously healthy 5-year-old boy comes to the ED with fever and sore throat for the past 2 days. His mother reports that he had fevers as high as 39^oC (102.2^oF), decreased oral intake despite acetaminophen every 4 hours, malaise, headache, and abdominal pain with 1 episode of nonbilious, nonbloody emesis 2 hours prior to coming to the ED. The boy’s 9-year-old brother was started on treatment for streptococcal pharyngitis 2 days earlier. On examination, you notice the patient has bilateral enlarged tonsils with exudates and bilateral tender anterior cervical lymphadenopathy, with an otherwise negative physical examination. Due to his symptoms and physical examination findings, you perform a rapid antigen test for GAS pharyngitis, which is positive. When you discuss treatment options with his mother, she remembers that when he was treated with amoxicillin for an ear infection 2 years prior, he had an anaphylactic reaction to the medication. You begin to consider what would be the best treatment option for this patient...

A previously healthy 7-year-old girl comes to the ED with a 3-day history of a sore throat and rash. Her father says she has felt warm to the touch, but he has not taken her temperature. She also has had multiple episodes of nonbilious, nonbloody emesis and nonbloody diarrhea over the past 2 days, as well as decreased appetite. Her father has been most concerned about the worsening rash on her hands and feet. The review of systems is otherwise unremarkable. She has not received any medication at home for her tactile fevers or throat pain. The father said her school sent a note home saying multiple children in the school have had the same symptoms, and he was encouraged to keep her home until she is completely better. On examination, you note that she has multiple vesicles on her buccal mucosa and tonsillar fauces, with a bilateral maculopapular rash on her hands and feet. Her examination is otherwise unremarkable. The girls's father asks whether his daughter needs antibiotics to shorten the duration of her illness. What do you tell her father is the best treatment for her current illness?

A previously healthy 15-year-old girl comes to the ED with fever and sore throat. With a muffled voice, she tells you she’s had a worsening sore throat for 8 days and fever to 38.6^oC (101.5^oF) for the past 5 days. She has been spitting her saliva for the past 3 days, as it has been hard for her to swallow, and she has had difficulty opening her mouth over the past 2 days. She says she had “strep throat” 2 years ago, but it was nothing like this. She has been taking ibuprofen with minimal relief of her current symptoms. On her review of symptoms, she says her left ear has been hurting for the past 5 days as well. In the ED, she is noted to have a fever of 38^oC (100.4^oC) with a heart rate of 130 beats/min, respiratory rate of 12 breaths/min, and a blood pressure of 100/65 mm Hg. On examination, you notice she has dry mucous membranes, capillary refill of 3 seconds, trismus, and, with the use of a tongue depressor, you see a very large left tonsil with exudates and fullness of the soft palate, as well as uvular deviation to the right side. Her physical examination is otherwise unremarkable. What should be the next steps in treating this patient?

Introduction

Children frequently present to emergency departments (EDs) and urgent care centers with the chief complaint of sore throat. One study estimates that only 20% to 30% of these children have an acute infection with streptococcal pharyngitis.¹ Group A Streptococcus (GAS) pharyngitis is the most common cause of bacterial pharyngitis in children and adolescents, and it may lead to suppurative and nonsuppurative complications. Suppurative complications include peritonsillar abscess (PTA) and, less commonly, streptococcal toxic shock syndrome (STSS) and other invasive infections. Nonsuppurative complications include acute rheumatic fever (ARF) and acute poststreptococcal glomerulonephritis (PSGN). Treatment of streptococcal pharyngitis is primarily aimed at preventing ARF,² which is rarely seen in developed nations,^3,4 but should be considered in areas with a large immigrant population.

Common pitfalls in the management of streptococcal pharyngitis include inappropriate testing of obvious viral etiologies and assuming that all positive screens/cultures indicate an acute infection rather than a carrier state of GAS. Inappropriate use of antimicrobials for acute pharyngitis has been a major contributor to the development of antibiotic-resistant bacteria.^5-7 It is imperative that emergency clinicians recognize the symptomatology and preserve the integrity of narrow-spectrum antibiotics for this common infection. This issue of Pediatric Emergency Medicine Practice focuses on recognizing the clinical signs and symptoms of GAS pharyngitis to facilitate appropriate treatment and to promote good antibiotic stewardship.

Critical Appraisal of the Literature

An online literature search was performed using the PubMed and Ovid MEDLINE^® databases, with the search terms pediatric streptococcal pharyngitis treatment, pediatric streptococcal pharyngitis diagnosis, streptococcal pharyngitis testing, pharyngitis treatment, pediatric sore throat, and sore throat. A total of 167 articles were found, and 153 articles were reviewed. Overall, there is a moderate amount of high-quality evidence evaluating the diagnosis and treatment of GAS pharyngitis. There were 13 meta-analyses found in journals and the Cochrane Database of Systematic Reviews that examined different aspects of GAS pharyngitis. Of the 153 articles included in this review, there were 36 randomized controlled trials examining current and possible future diagnostic and therapeutic options for GAS pharyngitis. The most recent Infectious Diseases Society of America (IDSA) guideline entitled, “Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America” was also reviewed.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.

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