Streptococcal pharyngitis

Background

• Strep pharyngitis
  • Peak in 5-15yr old
  • Rare in <2yr of age
  • Accounts for only 15-30% of pharyngitis

Clinical Features

• Sore throat
• Painful swallowing
• Fever
• N/V
• Tonsillar exudate
• Palatal petechiae

Diagnosis

Modified Centor Criteria

One point is given for each of the criteria:

• Absence of a cough
• Swollen and tender cervical lymph nodes
• Temperature >Template:Convert
• Tonsillar exudate or swelling
• Age less than 15 (a point is subtracted if age >44)^

Modified Centor score

Points	Probability of Strep	Management
1 or fewer	<10%	No antibiotic or culture needed
2	11–17%	Antibiotic based on rapid strep or culture
3	28–35%
4 or 5	52%	Empiric antibiotics

^Testing is not needed in children <3 years old as both group A strep and rheumatic fever are rare, except if they have a sibling with the disease.

Differential Diagnosis

Pharyngitis

• Viral pharyngitis
• Retropharyngeal abscess
• CMV pharyngitis
• Gonococcal pharyngitis

Others

• EBV pharyngitis
• Acute HIV
• Lemierre's Syndrome
• PTA
• Retropharyngeal Abscess
• Ludwig's Angina
• Epiglottitis

Treatment

Antibiotics

Treatment can be delayed for up to 9 days and still prevent major sequelae

Penicillin Options:

• Penicillin V 250mg PO BID x 10d (child) or 500mg BID x 10d (adolescent or adult)
• Bicillin L-A <27 kg: 0.6 million units; ≥27 kg: 1.2 million units IM x 1
• Amoxicillin 50 mg/kg once daily (maximum = 1000 mg) for 10 days

Penicillin allergic (mild):

• Cephalexin 20 mg per kg PO BID (maximum 500 mg per dose) x 10 days
• Cefadroxil 30 mg per kg PO QD (maximum 1 g daily) x 10 days

Penicillin allergic (anaphylaxis):

• Clindamycin 7 mg/kg/dose TID (maximum = 300 mg/dose) x 10 days
• Azithromycin 12 mg/kg PO once (maximum = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days
• Clarithromycin 7.5 mg/kg/dose PO BID (maximum = 250 mg/dose) x 10 days

Steroids

• Single dose of dexamethasone shortens duration of pain
  • Dexamethasone 0.6mg/kg PO

Complications

• Acute rheumatic fever
• Scarlet fever
• Streptococcal toxic shock syndrome
• Post-Streptococcal Glomerular Nephritis (PSGN)
• PANDAS syndrome
• Peritonsillar abscess
• Cervical lymphadenitis
• Mastoiditis

See Also

• Sore Throat

External Links

• SmartEM Pharyngitis

Source

• Tintinalli
• Rosen's
• Logan LK, McAuley JB, Shulman ST. [Macrolide treatment failure in streptococcal pharyngitis resulting in acute rheumatic Fever]. Pediatrics. 2012 Mar;129(3):e798-802. Epub 2012 Feb 6.