Upper Respiratory Infection symptoms like cough or sore throat are still some of the top reasons for Canadian emergency department visits, and will likely be even higher in the upcoming months and in Urgent Care Centres. The study and subsequent score excluded patients under 3 years of age as strep throat is very rare in this population. This score is easy to use as it requires no bloodwork or imaging and completed with a quick medical history, a thermometer and a penlight. It has also been validated in family clinic and ED settings and in pediatric populations, thus increasing the utility of this decision rule. Figure 2: Interpretation of Modified Centor Score and subsequent management 3.

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A more recent article on streptococcal pharyngitis is available. This is a corrected version of the article that appeared in print. BETH A. Patient information: See related handout on strep throat , written by the author of this article. Cough, coryza, and diarrhea are more common with viral pharyngitis. Available diagnostic tests include throat culture and rapid antigen detection testing. Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly.

Penicillin 10 days of oral therapy or one injection of intramuscular benzathine penicillin is the treatment of choice because of cost, narrow spectrum of activity, and effectiveness. Amoxicillin is equally effective and more palatable. Erythromycin and first-generation cephalosporins are options in patients with penicillin allergy. Although current guidelines recommend first-generation cephalosporins for persons with penicillin allergy, some advocate the use of cephalosporins in all nonallergic patients because of better GABHS eradication and effectiveness against chronic GABHS carriage.

Chronic carriers are at low risk of transmitting disease or developing invasive GABHS infections, and there is generally no need to treat carriers.

Whether tonsillectomy or adenoidectomy decreases the incidence of GABHS pharyngitis is poorly understood. At this time, the benefits are too small to outweigh the associated costs and surgical risks. Pharyngitis is diagnosed in 11 million patients in U. Group A beta-hemolytic streptococcus GABHS , the most common bacterial etiology, accounts for 15 to 30 percent of cases of acute pharyngitis in children and 5 to 20 percent in adults.

The infection is transmitted via respiratory secretions, and the incubation period is 24 to 72 hours. Use of clinical decision rules for diagnosing GABHS pharyngitis improves quality of care while reducing unwarranted treatment and overall cost. Penicillin is the treatment of choice for GABHS pharyngitis in persons who are not allergic to penicillin. Because the signs and symptoms of GABHS pharyngitis overlap extensively with other infectious causes, making a diagnosis based solely on clinical findings is difficult.

In patients with acute febrile respiratory illness, physicians accurately differentiate bacterial from viral infections using only the history and physical findings about one half of the time.

Cervical node lymphadenopathy and pharyngeal or tonsillar inflammation or exudates are common signs. Palatal petechiae and scarlatiniform rash are highly specific but uncommon; a swollen uvula is sometimes noted. Cough, coryza, conjunctivitis, and diarrhea are more common with viral pharyngitis.

The diagnostic accuracy of these signs and symptoms is listed in Table 1. The rational clinical examination. Does this patient have strep throat? The original Centor score uses four signs and symptoms to estimate the probability of acute streptococcal pharyngitis in adults with a sore throat. Patients with a score of zero or 1 are at very low risk for streptococcal pharyngitis and do not require testing i.

Patients with a score of 2 or 3 should be tested using RADT or throat culture; positive results warrant antibiotic therapy. Patients with a score of 4 or higher are at high risk of streptococcal pharyngitis, and empiric treatment may be considered.

Modified Centor score and management options using clinical decision rule. Other factors should be considered e. A clinical score to reduce unnecessary antibiotic use in patients with sore throat.

With correct sampling and plating techniques, a single-swab throat culture is 90 to 95 percent sensitive. RADT specificity ranges from 90 to 99 percent. Sensitivity depends on the commercial RADT kit used and was approximately 70 percent with older latex agglutination assays. Whether negative RADT results in children and adolescents require confirmatory throat culture is controversial. Other studies suggest that the sensitivity of newer optical immunoas-says approaches that of single-plate throat culture, obviating the need for back-up culture.

The precipitous drop in rheumatic fever in the United States, significant costs of additional testing and follow-up, and concerns about inappropriate antibiotic use are valid reasons why back-up cultures are not routinely performed. Streptococcal antibody titers are not useful for diagnosing streptococcal pharyngitis and are not routinely recommended. They may be indicated to confirm previous infection in persons with suspected acute poststreptococcal glomerulonephritis or rheumatic fever.

They may also help distinguish acute infection from chronic carrier status, although they are not routinely recommended for this purpose. GABHS pharyngitis is self-limited and resolves within a few days, even without treatment. Information from references 2 , and 18 through Non—group A beta-hemolytic streptococci groups C and G also can cause acute pharyngitis; these strains are usually treated with antibiotics, although good clinical trials are lacking. Fusobacterium necrophorum causes endemic acute pharyngitis, peritonsillar abscess, and persistent sore throat.

Untreated Fusobacterium infections may lead to Lemierre syndrome, an internal jugular vein thrombus caused by inflammation. Complications occur when septic plaques break loose and embolize. Empiric antibiotic therapy may reduce the incidence of complications. Effectiveness, spectrum of activity, safety, dosing schedule, cost, and compliance issues all require consideration. Penicillin, penicillin congeners ampicillin or amoxicillin , clindamycin Cleocin , and certain cephalosporins and macrolides are effective against GABHS.

Over the past 50 years, no increase in minimal inhibitory concentration or resistance to GABHS has been documented for penicillins or cephalosporins. Oral amoxicillin suspension is often substituted for penicillin because it tastes better. The medication is also available as chewable tablets. Five of eight trials to showed greater than 85 percent GABHS eradication with the use of amoxicillin. One randomized controlled trial RCT demonstrated comparable symptom relief with once-daily dosing, although like almost all studies of pharyngitis treatment, the trial was not powered to detect nonsuppurative complications.

Primary treatment recommended by current guidelines. Treatment for patients with penicillin allergy recommended by current guidelines. Information from references 2 , 17 through 20 , and 28 through Current U. Gastrointestinal side effects of erythromycin cause many physicians to instead prescribe the FDA-approved second-generation macrolides azithromycin Zithromax and clarithromycin Biaxin.

Azithromycin reaches higher concentrations in pharyngeal tissue and requires only five days of treatment. First-generation oral cephalosporins are recommended for patients with penicillin allergy who do not have immediate-type hypersensitivity to betalactam antibiotics. Bacteriologic failure rates for penicillin-treated GABHS pharyngitis increased from about 10 percent in the s to more than 30 percent in the past decade. Higher rates of GABHS eradication and shorter courses of therapy that are possible with cephalosporins may be beneficial.

Although cephalosporins are effective, the shift toward expensive, broad-spectrum second- and third-generation cephalosporin use is increasing. Numerous practice guidelines, clinical trials, and cost analyses give divergent opinions. Use Centor criteria see Figure 1.

Children: Yes. Who requires antibiotic treatment? Oral penicillin V Veetids; brand no longer available in the United States ; intramuscular penicillin G benzathine Bicillin L-A ; oral amoxicillin with equal effectiveness and better palatability in children. Differences in guidelines are best explained by whether emphasis is placed on avoiding inappropriate antibiotic use or on relieving acute GABHS pharyngitis symptoms.

Several U. A similar recommendation to omit confirmatory throat culture after negative RADT is likely for children. In patients treated within the preceding 28 days, RADT has similar specificity and higher sensitivity than in patients without previous streptococcal infection 0. Chronic carriers are at little to no risk of immune-mediated post-streptococcal complications because no active immune response occurs.

Unproven therapies such as long-term antibiotic use, treatment of pets, and exclusion from school and other activities have proved ineffective and are best avoided. Testing is unnecessary if clinical symptoms suggest viral upper respiratory infection. Antibiotic treatment may be appropriate in the following persons or situations: recurrent GABHS infection within a family; personal history of or close contact with someone who has had acute rheumatic fever or acute poststreptococcal glomerulonephritis; close contact with someone who has GAS infection; community outbreak of acute rheumatic fever, poststreptococcal glomerulonephritis, or invasive GAS infection; health care workers or patients in hospitals, chronic care facilities, or nursing homes; families who cannot be reassured; and children at risk of tonsillectomy for repeated GABHS pharyngitis.

The effect of tonsillectomy on decreasing risk for chronic or recurrent throat infection is poorly understood. A meta-analysis of children and adults with chronic pharyngitis comparing tonsillectomy with nonsurgical treatment was inconclusive.

Already a member or subscriber? Log in. Francis Hospital, Memphis. She also completed a faculty development fellowship at the Waco Tex. Faculty Development Center. Address correspondence to Beth A. Reprints are not available from the author. Author disclosure: Dr.

Adv Data. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis. Burden of acute sore throat and group A streptococcal pharyngitis in school-aged children and their families in Australia.

Aetiology of respiratory tract infections: clinical assessment versus serological tests. Br J Gen Pract. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. The validity of a sore throat score in family practice.


Diagnosis and Treatment of Streptococcal Pharyngitis

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Centor criteria

Taming the SRU. When evaluating a patient with sore throat, consider alternatives to group A streptococcal pharyngitis. Mimics include acute HIV, gonococcal pharyngitis, and infectious mononucleosis. The modified Centor score uses 5 factors to help guide clinical decision making:.


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A more recent article on streptococcal pharyngitis is available. This is a corrected version of the article that appeared in print. BETH A. Patient information: See related handout on strep throat , written by the author of this article. Cough, coryza, and diarrhea are more common with viral pharyngitis. Available diagnostic tests include throat culture and rapid antigen detection testing. Throat culture is considered the diagnostic standard, although the sensitivity and specificity of rapid antigen detection testing have improved significantly.

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