pem pearl: Group a strep pharyngitis
There has been a lot of discussion recently about the treatment of GAS in children. Here are the present evidence-based indications for treatment for strep pharyngitis:
1. Antibiotic treatment for any child 3 years of age and older with symptomatic pharyngitis or tonsillopharyngitis or scarlatiniform rash who have a positive microbiologic test for GAS (NAAT, rapid antigen test, or culture).
2. Antibiotic treatment for ALL children suspected to have acute rheumatic fever or post-streptococcal glomerulonephritis.
3. Antibiotic treatment for ALL children with acute rheumatic fever and a household contact with GAS.
4. Antibiotic treatment for children less than 3 years of age with prolonged nasal discharge, tender anterior cervical lymphadenopathy, and low-grade fever especially with a household contact with GAS.
5. Antibiotic treatment for pre-pubertal children with the acute onset of obsessive-compulsive disorder.
6. Antibiotic treatment for all children less than 3 years of age who are symptomatic and who have a positive microbiologic test for GAS (NAAT, rapid antigen test, or culture) with a household GAS contact.
Recommended treatment for strep pharyngitis:
1. Amoxicillin 50 mg/Kg/day PO (maximum 1000 mg per day) once daily or BID for 10 days
2. If penicillin IgE-mediated hypersensitivity reaction—azithromycin 12 mg/Kg/day (maximum 500 mg/dose) PO once daily for 5 days.
3. If penicillin and cephalosporins can not be used and macrolide resistance is a concern— clindamycin 7 mg/Kg/dose (maximum 300 mg/dose) PO TID for 10 days.
PROS for treatment of GAS:
1. The reason that acute rheumatic fever (ARF) cases are so low is because we are treating strep pharyngitis. If we stop the number of cases will rise.
2. ARF is not the only complication of GAS. Many hospitals have seen an increase in severe streptococcal infections including intracranial complications, and these children can have long-term complications.
3. If we are not going to treat GAS, why order the test?
4. From a medicolegal standpoint if a child has a positive strep test and is not treated and has a complication it will be hard to defend in the legal system.
CONS for treatment of GAS:
1. The incidence of ARF is very low in resource rich areas. Our country qualifies as resource rich.
2. The incidence of GAS in infants is very low.
3. Treating GAS for every positive test contributes to antibiotic resistance.
In my research most pediatric infectious disease experts recommend treatment per the recommendations. Some tips from them:
1. If you feel the child has a viral illness do not do a GAS test.
2. Use the Centor criteria in children over 3 years of age with less than 3 days of acute pharyngitis symptoms.
3. Use amoxicillin for treatment of GAS for antibiotic stewardship unless there is a contraindication.
4. Treat infants who test positive for GAS, are symptomatic, and have a household member with GAS.
1. Antibiotic treatment for any child 3 years of age and older with symptomatic pharyngitis or tonsillopharyngitis or scarlatiniform rash who have a positive microbiologic test for GAS (NAAT, rapid antigen test, or culture).
2. Antibiotic treatment for ALL children suspected to have acute rheumatic fever or post-streptococcal glomerulonephritis.
3. Antibiotic treatment for ALL children with acute rheumatic fever and a household contact with GAS.
4. Antibiotic treatment for children less than 3 years of age with prolonged nasal discharge, tender anterior cervical lymphadenopathy, and low-grade fever especially with a household contact with GAS.
5. Antibiotic treatment for pre-pubertal children with the acute onset of obsessive-compulsive disorder.
6. Antibiotic treatment for all children less than 3 years of age who are symptomatic and who have a positive microbiologic test for GAS (NAAT, rapid antigen test, or culture) with a household GAS contact.
Recommended treatment for strep pharyngitis:
1. Amoxicillin 50 mg/Kg/day PO (maximum 1000 mg per day) once daily or BID for 10 days
2. If penicillin IgE-mediated hypersensitivity reaction—azithromycin 12 mg/Kg/day (maximum 500 mg/dose) PO once daily for 5 days.
3. If penicillin and cephalosporins can not be used and macrolide resistance is a concern— clindamycin 7 mg/Kg/dose (maximum 300 mg/dose) PO TID for 10 days.
PROS for treatment of GAS:
1. The reason that acute rheumatic fever (ARF) cases are so low is because we are treating strep pharyngitis. If we stop the number of cases will rise.
2. ARF is not the only complication of GAS. Many hospitals have seen an increase in severe streptococcal infections including intracranial complications, and these children can have long-term complications.
3. If we are not going to treat GAS, why order the test?
4. From a medicolegal standpoint if a child has a positive strep test and is not treated and has a complication it will be hard to defend in the legal system.
CONS for treatment of GAS:
1. The incidence of ARF is very low in resource rich areas. Our country qualifies as resource rich.
2. The incidence of GAS in infants is very low.
3. Treating GAS for every positive test contributes to antibiotic resistance.
In my research most pediatric infectious disease experts recommend treatment per the recommendations. Some tips from them:
1. If you feel the child has a viral illness do not do a GAS test.
2. Use the Centor criteria in children over 3 years of age with less than 3 days of acute pharyngitis symptoms.
3. Use amoxicillin for treatment of GAS for antibiotic stewardship unless there is a contraindication.
4. Treat infants who test positive for GAS, are symptomatic, and have a household member with GAS.
