Streptococcal pharyngitis is an infection caused by a bacteria called Streptococcus pyogenes, also called Group A Streptococcus. Recently we discussed Strep throat infections and how its complications can have devastating effects on the family. Fortunately, this infection can be treated with antibiotics. Today I will talk about the antibiotic treatment of strep throat and what to expect if you got such a diagnosis. We arrive at strep throat diagnosis by obtaining a throat swab and sometimes going all the way to culture if the index of suspicion is high enough.
Recently we discussed Strep throat infections and how its complications can have devastating effects on the family. Fortunately, this infection can be treated with antibiotics. Today I will talk about the antibiotic treatment of strep throat and what to expect if you got such a diagnosis. We arrive at strep throat diagnosis by obtaining a throat swab and sometimes going all the way to culture if the index of suspicion is high enough.
The goals of treatment with antibiotics are to limit transmission to close contacts while reducing duration and effects of the infection and averting some of the serious complications that we discussed previously.
According to the CDC, each year between 1,100 and 1,600 people die due to invasive group A strep disease. Strep throat is not invasive and its complications are rare however we need to be aware of them as the consequences of these complications can be severe.
How is Strep Throat Infection Transmitted?:
The infection gets transmitted to people in close proximity to us especially when an infected person coughs or sneezes. Also sharing utensils with someone with an infection can transmit strep throat.
- Shared food utensils
- Shared drink
The Symptoms of Strep Throat Infection:
It is easy to mistake strep throat infection as just another viral respiratory infection. Urgent care centers often test patients for strep and make decisions based on the rapid test. The clinician, however also asks certain questions to help guide the decision making, as symptoms can and indeed do overlap between one illness and another. Below are some of the symptoms and history that the clinician identifies to make a case for or against strep throat infection.
- A sore throat that starts abruptly with painful swallowing
- Swollen lymph nodes in the neck
- Visible exudates on the posterior throat or pharynx
- Red spots on roof of mouth
- Skin rash
- History of someone close who has been diagnosed with strep throat, usually a family member
- Body aches
- Nausea, vomiting in the young
The Antibiotics Effect:
Antibiotics are most effective in hastening the resolution of symptoms if commenced within the first two days of symptoms. They also help reduce the infection-related complications like peritonsillar abscess and cervical lymphadenitis. One would ordinarily want to associate severity of symptoms with a higher likelihood of complications, but that has not been demonstrated in studies. In some cases, the rapid strep may be negative but the culture ends up positive after a couple of days. In fact, the patient may actually be feeling better. It is still important to treat as this will help limit transmission of the infection. There is some research that has demonstrated recurrence of strep throat more in children who received antibiotics at the first visit compared with those who got antibiotics 48 hours later. This is believed to be because of inadequate time for the body to build up immunity for the infection. The strategy of delaying antibiotics commencement in mild to moderate recurrent infection may be helpful in reducing recurrence.
Antibiotic use up to 9 days after onset of symptoms has been shown to indeed reduce the occurrence of acute rheumatic fever complication of strep throat infection. The same effect has not been seen in the preventing P.A.N.D.A.S. or glomerulonephritis. The most optimal prevention is when the antibiotic coverage is for 9 to 11 days.
The transmission of strep throat iń infection normally is about 35% once the organisms are present in the throat. The goal of antibiotics is to eradicate throat presence of the bacteria. Good clearance is often achieved with the administration of penicillin or amoxicillin. Some studies have demonstrated between 80% and 90% clearance of throat carriage after 24 hours of penicillin or amoxicillin. However, without antibiotics, the body's immune system eliminates throat carriage in up to 50% of infected patients after a full month.
Choice and Duration of Antibiotics Use In Strep Throat Infection:
The recommended duration of antibiotics treatment for strep throat is 10 days at least. This has been demonstrated to prevent the dreaded rheumatic fever complication. We commence treatment early since it is a form of secondary prevention. Thus by reducing transmission we are preventing others from getting strep throat. If it is not Group A strep throat, but a Group G or C then the antibiotics ought to be stopped after 5 days.
Penicillin is the antibiotic of choice. We sometimes use other related agents too like amoxicillin and ampicillin. Good but more expensive alternatives include macrolide group of antibiotics, cephalosporin group and clindamycin. We NEVER use and do not recommend Bactrim or fluoroquinolones for the treatment of strep throat infection as they do not eradicate the organism and may further put pressure of drug resistance on the antibiotic.
Intramuscular injection of procaine penicillin was found to be effective for the antibiotic treatment of strep throat and the prevention of rheumatic fever. However, more commonly we now use Penicillin G Benzathine (Bicillin L-A). When we use the injection, it is preferred to combine it in children with procaine penicillin as Bicillin C-R 900/300. Penicillin G provides bactericidal levels against group A strep for up to 21-28 days.
Oral Penicillin V is the medicine of choice that we use to treat strep throat infection. It is given for a full 10 days. We use 250 mg two to three times a day if the child is less than 27kg in weight or 500mg two to three times a day if the child is more than 27kg.
We use 250 mg two to three times a day if the child is less than 27kg in weight or 500mg two to three times a day if the child is more than 27kg for 10 days.
Many pediatricians use oral amoxicillin also and some prefer it because it has better gastrointestinal absorption and tastes better than penicillin.
Cephalosporins, usually of the first-generation can also be used, but we do not use them as first line treatment since they are much more expensive and have a broader spectrum.
I have had some patients who have a penicillin allergy. If the allergy did not have life-threatening symptoms, I would use cephalosporins. However, if there is a higher risk of life-threatening reaction, macrolide antibiotics like azithromycin are used. The down side to macrolides is that the resistance can be as high as 20%.
For the clinical symptoms, there is a scoring system that was developed and published in 1998 to help reduce the overuse of antibiotics . I have created a form here
Read a more detailed article here on the AAFP website.
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Omega Pediatrics Difference:At Omega Pediatrics in Roswell, Georgia we understand the challenges that parents face when their children develop symptoms late in the day or after hours. Many pediatric offices are closed after 4 pm however we are open every weekday up to 9 pm for walk-ins and we have telemedicine via evisits for our known patients. Our clinic is one of the easily accessible pediatric primary care clinics in Roswell and Alpharetta. We provide pediatric primary care to families in the North Fulton area. Some of our families live in Sandy Springs, Johns Creek, Duluth and Cumming.
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