Streptococccal sore throat
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Streptococcal Sore Throat
Anas Bahnassi PhD
Pharmacotherapy of Infectious Diseases
Anas Bahnassi 2014
A Case-Based Approach
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hGoals of Therapy
• Provide symptomatic relief.
• Prevent suppurative complications, e.g. mastoiditis, cervical lymphadentitis.
• Prevent nonsuppurative commplications, e.g. acute rheumatic fever.
• Prevent spread of group A streptococci to contacts.
Anas Bahnassi 2014
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hInvestigations
• Culturing group A streptococci is needed in a child:
– > 3 year old.
– Acute sore throat.
– Lacks signs of viral URT infection.
– Has the sore throat symptoms.
Anas Bahnassi 2014
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InvestigationsClinical Diagnosis of Streptococcal Throat
• Adenitis.• Positive throat cultures.
Although not diagnostic:• Signs: tender cervical adenopathy, erythematous
pharynx and tonsils, pharyngeal exudate, excoriated nares, scarlatiniform rash.
• Symptoms: sore throat, pain on swallowing, headache, abdominal pain, nausea, vomiting, and feer.
Anas Bahnassi 2014
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hLaboratory Diagnosis
• Throat culture “Gold Standard” results in 24-48 hrs.
• Repeat cultures are not necessary in asymptomatic patients.
• Antigen screening of throat secretion is fast (7-70 mins) but sensetivity (<90%). Too low to rule out streptococcal infection in children and adolescents.
• If Antigen screening is negative or unavailable:– Hold antibiotics for 48hrs
– Perform throat culture.
– This procedure does not increase the chance of rheumatic fever but avoids the unnecessary use of antibiotics.
Anas Bahnassi 2014
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hSelected Pathogens of Acute Pharyngitis:
• Viruses: (Adenoviruses, cytomegalovirus, Epistein=Barr, enteroviruses, influenza, herpes simplex virus, and parainfluenza virus)
• Group A β-hemolytic streptococci (children 15-30%, Adults 5-10%)
• Group C and G β-hemolytic streptococci.• Neisseria gonorrheae (consider child abuse).• Mycoplasma pneumoniae.• Chlamydia trachomatis.• Chlamydophila pneumoniae.• Corynebacterium diphtheriae.• Archanobacterium hemolyticum.
Anas Bahnassi 2014
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hManagement of Acute Pharyngitis
Anas Bahnassi 2014
Acute Sore ThroatClinical Assessment
Signs and Symptoms of Group A Streptococcal Pharyngitis
Rapid Antigen Test Throat Culture Immediate investigation not essential, but
diagnosis of streptococcal pharyngitis not ruled out
+ve -ve +ve -ve
Antibiotic and Symptomatic Treatment
Symptomatic Treatment Only
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Therapeutic ChoicesNonpharmacologic
• Strict handwashing to prevent spread of infection.
• Exclude from school or daycare for 24 hours after antimicrobial therapy is begun.
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Therapeutic ChoicesPharmacologic
• Analgesics:– APAP.
– Ibuprofen.
– Lozenges, gargles, etc…
• Antibiotics:– Antibiotic therapy for group A streptococcal pharyngitis can shorten
the course of acute illness and prevent both suppurativenonsuppurative complications if started early in the illness.
– Penicillin is the DRUG of CHOICE.
– Cephalosporins are effective but should not replace penicillin.
– Amoxicillin suspension is more palatable than penicillin for children.
– Erythromycin can be used for patients with penicillin allergies.
Anas Bahnassi 2014
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Cephalo-sporins
Cefadroxil Adults:1g/day as a single dose or BID X10d
Hyper-sensitivity
Use if treatment with Penicillin fails
$$$
Cefixime Adults and Children >12yrs400mg/d X10days
Children 6m-12yrs8mg/kg/d X10days
Hyper-sensitivity
Use if treatment with Penicillin fails
Available in suspension.
$$$$
Cephalexin Adults:250mg QID X10d
Children:25-50mg/kg/day divided QID X10d
Hyper-sensitivity
Use if treatment with Penicillin fails
Available in suspension.
$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Cephalo-sporins
Cefprozil Adults and Children>12yrs500mg/d X10days
Children 6m-12yrs15mg/kg/d divided
BID
Hyper-sensitivity
Use if treatment with Penicillin fails
Available in suspension.
$$$$
Cefuroxime Adults and Children>12yrs250mg BID X10days
Children 3m-12yrs20mg/kg/d divided BIDX10days
Hyper-sensitivity
Use if treatment with Penicillin fails
Available in suspension.
Add milk or juice prior to dose.
$$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Ketolides Telithromycin Adults 800mg/day once X5days
Diarrhea Use if treatment with β-lactam fails
Telithromycin: Atorvastatin,Lovastatin, Simvastatin, Itraconazole, Ketoconazole.
Digoxin levels.
Contraindicated with ergot, pimozide and disopyramide.
$$$$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Linco-semides
Clindamycin Adults 600mg/day BID-QID X10 days
Children20-30mg/kg/dayDivided TID X10 days
Diarrhea
C.Difficile
Alternative to Erythomycin
Maybe used in symptomatic patients with multiple pharyngitis
Available in suspension.
$$$$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Macro-lides
Azithromycin Adults 500mg on day 1then 250 on days 2-5
Children12mg/kg/dayX 5 days.
Lower GI effects than Eryth.
Available in susp.
Less likely to interact with other meds.
$$
Clarithromycin Adults 250mg BID X10d days
Children15mg/kg/dayDivided Bid X 10 days.
Lower GI effects than Eryth.
Available in susp.
Clarithromycin: Atorvastatin,Lovastatin, Simvastatin, prednisone, theophylline.
$$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Macro-lides
Erythromycin Adults 1g/d divided BID-QID X10d1hr prior meals to prevent interactions.
Nausea, vomiting, epigastricdistress, diarrhea, elevated liver enzymes, cholestaticjaundice.
Alternative to penicillin.
Clarithromycin: Atorvastatin,Lovastatin, Simvastatin, prednisone, theophylline.
$$
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Antibiotic Treatment Recommendations
Anas Bahnassi 2014
Class Drug Dose ADR Comments Cost
Penicillin Amoxicillin 40mg/kg/d divided BID-TID X10days
Well tolerated
Available in chewable andsuspension
$$
Penicillin Adults: 330mg TID or 600mg BID X 10 days.Children: 25-50mg/kg/d divided BID
AnaphylaxisGI distressDiarrhea.
DRUG of Choice $
Amox/Clav Adults: 500mg BID X10 daysChildren: 40mg/kg/d divided TID
GI distressDiarrhea.
Maybe used in symptomatic patients with multiple pharyngitis
Available in suspension.
$$
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hTherapeutic Tips
• Early institution of antibiotic therapy shortens the duration of fever, cervical adenitis, pharyngeal infections, and hastens the overall clinical improvement.
• Early treatment can hasten the return of children to school and reduce the number of days out of work.
• Since there is no efficient way to differentiate acutely infected child and carrier of group A streptococci, all systemic patients with positive culture should be treated.
• Unfortunately Penicillin (Drug of Choice of Acute pharangitis) often fails to eradicate pharyngeal streptococcal carriage, Some advocate the use of clindamycin (20mg/kg/d TID X10d max 600mg/d) or the addition of rifampin (20mg/kg/d TID X10d max 600mg/d) for the final 4 days of penicillin therapy.
Anas Bahnassi 2014
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Pharmacotherapy:Infectious Diseases:
Anas Bahnassi PhD
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http://www.linkedin.com/in/abahnassiAnas Bahnassi 2014