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Could my Child’s Sore Throat be Strep? We asked Paediatric Nurse Practitioners Aliya Jaffer and Mollie McConnell for the Answers.

November 2015 “Ask the NP” Edition

Is it Strep Throat?

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With cold and influenza season starting this month, those dreadful sore throats are also right around the corner. Unfortunately, it’s challenging to differentiate between strep throat and a viral infection and, every year, people flock to their primary care provider, walk in clinics and the Emergency Department worried that their symptoms may require treatment with antibiotics. The reality is that many people are unnecessarily treated with antibiotics each year without a proven group A streptococcal infection, which leads to unnecessary cost and microbial resistance.

How do we avoid this?

Here is a quick refresher on strep throat and its management.
• Group A streptococcus is a common bacterial cause of throat infections, accounting for 5-15% of throat infections in adults and 20-30% of infections in children.
• Like viral infections, strep throat is a self-resolving disease!
• However, treatment of strep throat is important for the prevention of acute rheumatic fever and glomerulonephritis, as well as other serious complications that can arise from the formation of pus and abscesses (eg. mastoiditis, cervical lymphadentitis, retropharyngeal abscesses, or invasive infections)
* Note: The risk of acute rheumatic fever is rare in children < 3 and in adults
• It is impossible to differentiate between streptococcal and non-streptococcal (usually viral) throat infections based on clinical findings alone. Criteria have been established to help care providers estimate the likelihood of viral versus bacterial throat infections.

These criteria are summarized in the following list:
Group A Streptococcal Infection
• Sudden onset of sore throat
• Age 5-15 years
• Winter and early spring presentation
• History of exposure to documented group A streptococcal pharyngitis
• Clinical features: Fever, Headache, Nausea, vomiting, or abdominal pain, Tonsillar exudates, Palatal petechiae,Tender anterior cervical nodes and
Scarlatiniform rash

Viral Infection
• Absence of fever
• Presence of other clinical features commonly associated with viral illnesses such as: Conjunctivitis, Cough, Congestion, Runny nose, Diarrhea, Hoarseness and Ulcers

How is Strep Throat Diagnosed?

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Diagnosis of strep throat can be made by a positive Rapid Antigen Detection Test (RADT) or a positive throat culture (gold standard). The rapid strep test has excellent specificity but limited sensitivity. If you suspect strep pharyngitis and the rapid test is negative, you should obtain a throat culture for confirmation.

 

Clinical Tools Available

Clinical tools (such as the McIsaac Criteria) have been developed to help identify patients who are at a high and low risk of streptococcal infection.  In general, age between 3-15 years, fever, the absence of cough, tender anterior lymph nodes, and tonsillar exudates are suggestive of infection. The presence of ≥ 3 of these warrants a test. When in doubt, swab the throat!

When Should Antibiotics be Prescribed

Antibiotics should only be prescribed for confirmed group A streptococcal throat infections. Penicillin and Amoxicillin are typical first line agents used to treat these infections. Amoxicillin may be administered once daily (maximum dose 1000 mg) as per the IDSA guideline. Clindamycin, clarithromycin, and azithromycin may be used in cases of penicillin allergy.

Supportive Care

Strep throat or not, supportive care with fluids, rest, analgesics and topical agents in various forms such as rinses, sprays, and lozenges, can give temporary symptomatic relief.

Chronic Carriers of Group A Streptococcus (the bacteria that causes strep throat)

Some people are chronic carriers of group A streptococcus in their throat. A throat swab when asymptomatic can be used to confirm chronic carrier status.
Carriers do not typically require additional antibiotic therapy – they are at low risk of developing any complications and are unlikely to spread the infection to close contacts.

 

More information and details can be found in the Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America available from http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.full

 

“Ask the NP” November 2015 edition developed by:

Aliya Visram Jaffer

Aliya Jaffer, MN, NP-Pediatrics

Paediatric Nurse Practitioner

Paediatric Emergency Medicine & General Paediatrics Streamlined Care Unit at The Hospital For Sick Children

 

 

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Mollie McConnell, MSN, NP-Pediatrics, CPNP-AC

Paediatric Nurse Practitioner

Paediatric Emergency Medicine & General Paediatrics Streamlined Care Unit at The Hospital For Sick Children

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