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.
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 39oC (102.2oF), 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 38.6oC (101.5oF) 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 38oC (100.4oC) 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?
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.
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.
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.
The presence of cough, coryza, diarrhea, hoarseness, rhinorrhea, discrete ulcerative lesions in the mouth, or symptoms lasting > 5 days argues against the need for diagnostic testing for GAS.
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Why and When to Use, and Next Steps
Why to Use
Most pharyngitis is viral and does not respond to antibiotic treatment. The Centor Score attempts to predict which patients will have culture-confirmed GAS infections of the pharynx, to help determine which patients to test in the first place.
The newer FeverPAIN Score is similar, but the Centor Score has the advantage of distinguishing adolescents and young adults from preadolescents, which is important because streptococcal carrier rates for preadolescents are higher than for adolescents and young adults, and older patients exhibit more severe symptoms and develop suppurative complications more frequently (Mitchell et all 2011).
Steroids and NSAIDs improve symptoms; antibiotics are often indicated in GAS pharyngitis, but do not prevent its suppurative complications, such as peritonsillar abscess.
Graham Walker, MD
Department of Emergency Medicine
Kaiser Permanente San Francisco
San Francisco, CA
Rachel Kwon, MD
It is still important to carefully consider patients with symptom duration longer than 3 days, even though the Centor Score does not apply. While symptoms are not compatible with a diagnosis of acute pharyngitis, these patients require evaluation for suppurative complications (eg, peritonsillar abscess or Lemierre syndrome), or viral infections in adult patients (eg, infectious mononucleosis or acute HIV) (Centor 2017).
The goal of the original study by Centor et al was to develop criteria to diagnose GAS infection in adult patients presenting to the emergency department with a sore throat (Centor et al 1981). The original model designated 4 criteria: tonsillar exudates; swollen, tender anterior cervical nodes; absence of cough; and history of fever. Patients exhibiting all 4 variables had a 56% probability of having a group A beta strep-positive culture; the probability was 32% in patients with 3 variables, 15% in patients with 2 variables, 6.5% in patients with 1 variable, and 2.5% in patients with none of the variables.
The Centor Score was later modified to include age (McIsaac et al 1998) and was validated (McIsaac et al 2004) for use in both children and adults presenting with a sore throat. McIsaac et al (1998) determined that using the Centor Score would reduce the number of unnecessary initial antibiotic prescriptions by 48%, without increasing throat culture use.
The Centor Score and its modifications were derived in relatively small samples (n = 286 and n = 521, respectively). In order to more precisely classify the risk of GAS infection, Fine et al (2012) performed a national-scale validation of the score on a geographically diverse population of > 140,000 patients presenting in a clinical setting. The study was carried out over the course of more than a year, mitigating any impact of seasonality of GAS incidence on the results. This analysis provided more precise interpretations of risk for each category of the Centor Score and still fell within the 95% confidence interval of the original study by Centor et al (1981), which had a much smaller sample size.
In their comparison of the Centor Score with other identification and treatment strategies, McIsaac et al (2004) found that use of the score resulted in fewer overall tests (throat cultures and rapid antigen detection tests) per person, but more throat cultures (96.1% of adults) than other strategies. As a result, the Centor Score represented a compromise, requiring the least diagnostic testing, providing 100% sensitivity and greater than 90% specificity in both children and adults, and producing significant reductions in unnecessary use of antibiotics, compared with other strategies.
Harris et al (2016) encouraged the use of the Centor Score primarily to identify patients with a low probability of GAS pharyngitis who do not warrant further testing, citing the low positive predictive value of the criteria.
Robert M. Centor, MD
Michelle N. Vazquez, MD; Jennifer E. Sanders, MD
December 2, 2017
January 1, 2021
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Infectious Disease CME and 0.5 Pharmacology CME credits
Date of Original Release: December 1, 2017. Date of most recent review: November 15, 2017. Termination date: December 1, 2020.
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