CHARLOTTESVILLE, Va. Thirty years ago, most pediatricians were appropriately concerned about streptococcal pharyngitis because of the occurrence of acute rheumatic fever. When the incidences of rheumatic fever waned over the following two decades, this medical interest declined, as well. But the situation has changed recently, and it might be time to get back to the basics and become more aggressive in treating sore throats in children.
"There's now a greater interest in strep than there was a decade ago," said Gregory F. Hayden, MD, professor of pediatrics at the University of Virginia. Hayden pointed to a resurgence of localized clusters of rheumatic fever, an increase in bacteremic diseases, such as pneumonia, and cases of myositis and necrotizing fasciitis as a basis for concern.
"The message is that it's time to get back to basics and treat these infections with the antibiotics that we know work well," said Hayden. But it brings up questions about whether to culture throats and the reliability of the cultures.
--- Strep throat.
According to Hayden, the single most reliable finding that would suggest a positive culture for streptococcal pharyngitis is tender and large anterior cervical nodes. However, "there is great clinical overlap between streptococcal and viral pharyngitis and symptoms suggestive of other diseases," said Hayden. While the presentation of strep has not changed, the problems associated with a failure to treat b-hemolytic streptococcal infections have re-emerged.
"A culture can only be as good as the throat swab specimen," Hayden said. "The first time is always the easiest; use a tongue blade to minimize contamination and get to the back of the throat. Sometimes having an older child sit on a table with his or her back to a wall of the room helps," he suggested. This prevents the natural response of withdrawing the head when the throat is swabbed.
While the throat culture is good, and considered the gold standard, it is not perfect. "There are problems of false positives, lab errors, false negatives, inhibition of growth (perhaps the child just gargled with something with antibacterial properties) or maybe the family recently used an old antibiotic left from a previous infection," Hayden said.
The message is clear: physicians must culture the throat to effectively diagnose and treat group A b-hemolytic streptococcal pharyngitis. "The method [of detection] for pharyngitis is a throat culture," Hayden said, "and in most situations it's just not good medicine if we treat sore throats without doing a rapid test or culture first."
Treating strep pharyngitis has not changed much, according to Hayden. "We must, however, limit antibiotic treatment to those children who really need it," Hayden said.
Hayden still prefers using penicillin V for treating strep pharyngitis in children. However, a recent study published in the British Journal of Medicine indicated that once daily amoxicillin at 50 mg/kg/day (maximum of 750 mg) was compared with the traditional penicillin V treatment of 250 mg, three times daily.
"The clinical responses looked fine and the strep eradication looked fine, but I am not ready to make the switch until these findings are confirmed in other settings," Hayden said.
Concluding his treatment preferences, Hayden indicated that if the choice is to treat with oral therapy, "use penicillin V, 250 mg, three times daily for 10 days," as studies have shown that five to seven day therapies do not work. "I am not happy using penicillin V twice daily and erythromycin should still be used if the child is allergic to penicillin."
For the treatment of relapsing infections, Hayden suggested that group A strep is confirmed, compliance with medications is ensured and that it is verified that the organism is sensitive to the antibiotic. "This is particularly true with erythromycin," Hayden said. Consider an alternative regimen such as cephalosporin or amoxicillin clavulanate (Augmentin, SmithKline Beecham) and "culture symptomatic family members and treat if appropriate."
For more information:
- Shvartzman P, Tabenkin H, Rosentzwang A, et al. Treatment of streptococcal pharyngitis with amoxicillin once a day. British medical Journal 1993;306:1170-72.
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