A culture positive case of streptococcal pharyngitis with typical tonsillar exudate in a 16-year-old.
|Classification and external resources|
Streptococcal pharyngitis, streptococcal tonsillitis, or streptococcal sore throat (known colloquially as strep throat) is a type of pharyngitis caused by a group A streptococcal infection. It affects the pharynx including the tonsils and possibly the larynx. Common symptoms include fever, sore throat, and enlarged lymph nodes. It is the cause of 15–40% of sore throats among children and 5–15% in adults.
Strep throat is a contagious infection, spread through close contact with an infected individual. A definitive diagnosis is made based on the results of a throat culture. However, this is not always needed as treatment may be decided based on symptoms. In highly likely or confirmed cases, antibiotics are useful to both prevent complications and speed recovery. Potential complications include rheumatic fever.
Signs and symptoms
Other symptoms include: headache, nausea and vomiting, abdominal pain, muscle pain, or a scarlatiniform rash or palatal petechiae, the latter being an uncommon but highly specific finding. The incubation period and thus the start of symptoms for strep throat is between one to three days post contact. Strep throat is unlikely when any of the symptoms of red eyes, hoarseness, runny nose, or mouth ulcers are present. It is also unlikely when there is no fever.
Mouth wide open showing the throat
A throat infection which on culture tested positive for group A streptococcus. Note the large tonsils with white exudate.
Strep throat is caused by group A beta-hemolytic streptococcus (GAS or S. pyogenes). Other bacteria such as non–group A beta-hemolytic streptococci and fusobacterium may also cause pharyngitis. It is spread by direct, close contact with an infected person and thus crowding as may be found in the military and schools increases the rate of transmission. It has been found that dried bacteria in dust are not infectious, although moist bacteria on toothbrushes or similar items can persist for up to fifteen days. Rarely, contaminated food can result in outbreaks. Of children with no signs or symptoms, 12% carry GAS in their pharynx, and, after treatment, approximately 15% remain carriers.
|Points||Probability of Strep||Management|
|1 or fewer||<10%||No antibiotic or culture needed|
|2||11–17%||Antibiotic based on culture or RADT|
|4 or 5||52%||Empiric antibiotics|
A number of scoring systems exist to help with diagnosis; however, their use is controversial due to insufficient accuracy. The modified Centor criteria is based on 5 criteria and indicates the probability of a streptococcal infection.
One point is given for each of the criteria:
- Absence of a cough
- Swollen and tender cervical lymph nodes
- Temperature >38.0 °C (100.4 °F)
- Tonsillar exudate or swelling
- Age less than 15 (a point is subtracted if age >44)
A score of one may indicated no treatment or culture is needed or it may indicate the need to perform further testing if other high risk factors such as a family member has the disease. The Infectious Disease Society of America recommends against empirical treatment and considers antibiotics only appropriate following positive testing. Testing is not needed in children under three as both group A strep and rheumatic fever are rare, except if they have a sibling with the disease.
A throat culture is the gold standard for the diagnosis of streptococcal pharyngitis with a sensitivity of 90–95%. A rapid strep test (also called rapid antigen detection testing or RADT) may also be used. While the rapid strep test is quicker, it has a lower sensitivity (70%) and statistically equal specificity (98%) as throat culture. In areas of the world were rheumatic fever is uncommon, a negative rapid strep test is sufficient to rule out the disease.
A positive throat culture or RADT in association with symptoms establishes a positive diagnosis in those in which the diagnosis is in doubt. In adults, a negative RADT is sufficient to rule out the diagnosis. However, in children a throat culture is recommended to confirm the result. Asymptomatic individuals should not be routinely tested with a throat culture or RADT because a certain percentage of the population persistently "carries" the streptococcal bacteria in their throat without any harmful results.
As the symptoms of streptococcal pharyngitis overlap with other conditions, it can be difficult to make the diagnosis clinically. Coughing, nasal discharge, diarrhea, and red, irritated eyes in addition to fever and sore throat are more indicative of a viral sore throat than of strep throat. The presence of marked lymph node enlargement along with sore throat, fever and tonsillar enlargement may also occur in infectious mononucleosis.
Tonsillectomy may be a reasonable preventive measure in those with frequent throat infections (more than three a year). The benefits are, however, small and episodes typically lessen in time regardless of measures taken. Recurrent episodes of pharyngitis which test positive for GAS may also represent a person who is a chronic carrier of GAS who is getting recurrent viral infections. Treating people who have been exposed but who are without symptoms is not recommended. Treating people who are carriers of GAS is not recommended as the risk of spread and complications is low.
Untreated streptococcal pharyngitis usually resolves within a few days. Treatment with antibiotics shortens the duration of the acute illness by about 16 hours. The primary reason for treatment with antibiotics is to reduce the risk of complications such as rheumatic fever and retropharyngeal abscesses and they are effective if given within 9 days of the onset of symptoms.
Analgesics such as non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol (acetaminophen) help significantly in the management of pain associated with strep throat. Viscous lidocaine may also be useful. While steroids may help with the pain they are not routinely recommended. Aspirin may be used in adults but is not recommended in children due to the risk of Reye's syndrome.
The antibiotic of choice in the United States for streptococcal pharyngitis is penicillin V due to safety, cost, and effectiveness. Amoxicillin is preferred in Europe. In India, where the risk of rheumatic fever is higher, intramuscular benzathine penicillin G is the first choice for treatment. Appropriate antibiotics decrease the average 3–5 day duration of symptoms by about one day, and also reduce contagiousness. They are primarily prescribed out of a motivation to reduce rare complications such as rheumatic fever and peritonsillar abscess. The arguments in favour of antibiotic treatment should be balanced by the consideration of possible side effects, and it is reasonable to suggest that no antimicrobial treatment be given to healthy adults who have adverse reactions to medication. Antibiotics are prescribed for strep throat at a higher rate than would be expected from its prevalence. Erythromycin and other macrolides or clindamycin are recommended for people with severe penicillin allergies. First generation cephalosporins may be used in those with less severe allergies and some evidence supports cephalosporins as superior to penicillin. Streptococcal infections may also lead to acute glomerulonephritis; however, the incidence of this side effect is not reduced by the use of antibiotics.
The symptoms of strep throat usually improve irrespective of treatment within three to five days. Treatment with antibiotics reduces the risk of complications and transmission; children may return to school 24 hours after antibiotics are administered. The risk of complications in adults is low. In children, acute rheumatic fever is rare in most of the developed world. It is, however, the leading cause of acquired heart disease in India, sub-Saharan Africa and some parts of Australia.
Complications arising from streptococcal throat infections include:
The economic cost of the disease in the United States in children is ~$350 million.
Pharyngitis, the broader category into which Streptococcal pharyngitis falls, is diagnosed in 11 million people annually in the United States. It is the cause of 15–40% of sore throats among children and 5–15% in adults. Cases usually occur in late winter and early spring.
- "streptococcal pharyngitis" at Dorland's Medical Dictionary
- Shaikh N, Leonard E, Martin JM (September 2010). "Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis". Pediatrics 126 (3): e557–64. doi:10.1542/peds.2009-2648. PMID 20696723.
- Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.
- Shulman, ST; Bisno, AL; Clegg, HW; Gerber, MA; Kaplan, EL; Lee, G; Martin, JM; Van Beneden, C (Sep 9, 2012). "Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America.". Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 55 (10): e86–102. doi:10.1093/cid/cis629. PMID 22965026.
- Brook I, Dohar JE (December 2006). "Management of group A beta-hemolytic streptococcal pharyngotonsillitis in children". J Fam Pract 55 (12): S1–11; quiz S12. PMID 17137534.
- Hayes CS, Williamson H (April 2001). "Management of Group A beta-hemolytic streptococcal pharyngitis". Am Fam Physician 63 (8): 1557–64. PMID 11327431.
- Baltimore RS (February 2010). "Re-evaluation of antibiotic treatment of streptococcal pharyngitis". Curr. Opin. Pediatr. 22 (1): 77–82. doi:10.1097/MOP.0b013e32833502e7. PMID 19996970.
- Lindbaek M, Høiby EA, Lermark G, Steinsholt IM, Hjortdahl P (2004). "Predictors for spread of clinical group A streptococcal tonsillitis within the household". Scand J Prim Health Care 22 (4): 239–43. doi:10.1080/02813430410006729. PMID 15765640.
- Rakel, edited by Robert E. Rakel, David P. Textbook of family medicine (8th ed. ed.). Philadelphia, PA.: Elsevier Saunders. p. 331. ISBN 9781437711608.
- Cohen, JF; Cohen, R; Levy, C; Thollot, F; Benani, M; Bidet, P; Chalumeau, M (6 January 2015). "Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study.". CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne 187 (1): 23–32. PMID 25487666.
- Smith, Ellen Reid; Kahan, Scott; Miller, Redonda G. (2008). In A Page Signs & Symptoms. In a Page Series. Hagerstown, Maryland: Lippincott Williams & Wilkins. p. 312. ISBN 0-7817-7043-2.
- Lean, WL; Arnup, S; Danchin, M; Steer, AC (October 2014). "Rapid diagnostic tests for group A streptococcal pharyngitis: a meta-analysis.". Pediatrics 134 (4): 771–81. PMID 25201792.
- Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH (July 2002). "Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America". Clin. Infect. Dis. 35 (2): 113–25. doi:10.1086/340949. PMID 12087516.
- Ebell MH (2004). "Epstein-Barr virus infectious mononucleosis". Am Fam Physician 70 (7): 1279–87. PMID 15508538.
- Johnson BC, Alvi A (March 2003). "Cost-effective workup for tonsillitis. Testing, treatment, and potential complications". Postgrad Med 113 (3): 115–8, 121. doi:10.3810/pgm.2003.03.1391. PMID 12647478.
- van Staaij, BK; van den Akker, EH; van der Heijden, GJ; Schilder, AG; Hoes, AW (January 2005). "Adenotonsillectomy for upper respiratory infections: evidence based?". Archives of Disease in Childhood 90 (1): 19–25. doi:10.1136/adc.2003.047530. PMC 1720065. PMID 15613505.
- Burton, MJ; Glasziou, PP (Jan 21, 2009). "Tonsillectomy or adeno-tonsillectomy versus non-surgical treatment for chronic/recurrent acute tonsillitis.". Cochrane database of systematic reviews (Online) (1): CD001802. doi:10.1002/14651858.CD001802.pub2. PMID 19160201.
- Thomas M, Del Mar C, Glasziou P (October 2000). "How effective are treatments other than antibiotics for acute sore throat?". Br J Gen Pract 50 (459): 817–20. PMC 1313826. PMID 11127175.
- "Generic Name: Lidocaine Viscous (Xylocaine Viscous) side effects, medical uses, and drug interactions". MedicineNet.com. Retrieved 2010-05-07.
- Wing, A; Villa-Roel, C; Yeh, B; Eskin, B; Buckingham, J; Rowe, BH (May 2010). "Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature.". Academic Emergency Medicine 17 (5): 476–83. doi:10.1111/j.1553-2712.2010.00723.x. PMID 20536799.
- Bonsignori F, Chiappini E, De Martino M (2010). "The infections of the upper respiratory tract in children". Int J Immunopathol Pharmacol 23 (1 Suppl): 16–9. PMID 20152073.
- Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR (March 2001). "Principles of appropriate antibiotic use for acute pharyngitis in adults" (PDF). Ann Intern Med 134 (6): 506–8. doi:10.7326/0003-4819-134-6-200103200-00018. PMID 11255529.
- Linder JA, Bates DW, Lee GM, Finkelstein JA (November 2005). "Antibiotic treatment of children with sore throat". J Am Med Assoc 294 (18): 2315–22. doi:10.1001/jama.294.18.2315. PMID 16278359.
- Pichichero, M; Casey, J (June 2006). "Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis.". European Journal of Clinical Microbiology & Infectious Diseases 25 (6): 354–64. doi:10.1007/s10096-006-0154-7. PMID 16767482.
- Casey, JR; Pichichero, ME (March 2007). "The evidence base for cephalosporin superiority over penicillin in streptococcal pharyngitis.". Diagnostic microbiology and infectious disease 57 (3 Suppl): 39S–45S. doi:10.1016/j.diagmicrobio.2006.12.020. PMID 17292576.
- "UpToDate Inc.".
- Stevens DL, Tanner MH, Winship J et al. (July 1989). "Severe group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A". N. Engl. J. Med. 321 (1): 1–7. doi:10.1056/NEJM198907063210101. PMID 2659990.
- Hahn RG, Knox LM, Forman TA (May 2005). "Evaluation of poststreptococcal illness". Am Fam Physician 71 (10): 1949–54. PMID 15926411.