Strep throat: it sounds so bad, as if the throat has been “strepped” (whatever that means) by some nasty bug. Confronted with a child who complains of a sore throat, most parents make a quick trip to the doctor to see if it’s strep throat.
Strep is short for Group A Streptococcus bacteria, the organisms responsible for 20 to 30 percent of sore throats among children aged 5 to 15 and 5 to 15 percent of those in adults. Strep throat is dangerous because, untreated, it can lead to serious complications such as rheumatic fever and inflammation of the kidneys, which can lead to kidney failure. But it’s not as common as most parents think and, as a result, doctors have to be judicious about making a diagnosis and starting treatment.
The most frequent cause of a sore throat is a viral infection, usually related to a cold. A sore throat may also be caused by an allergy or inflammation, perhaps following vigorous cheering at a football game. In none of these cases will antibiotic treatment be effective.
If the patient has a runny nose, stuffed nasal passages, coughing, sneezing and hoarse voice, it’s very unlikely that the problem is strep throat, and there is probably no reason to visit the doctor unless symptoms get worse.
If you have had strep throat yourself, you probably know the signs:
• sore throat, usually appearing quickly;
• pain when you swallow;
• fever over 101 degrees Fahrenheit;
• swollen tonsils and lymph nodes; and
• a bright red throat with white or yellow spots.
When these symptoms are present, a visit to a doctor is recommended, and it’s tempting for the physician to make a diagnosis on the basis of suspicion and prescribe antibiotics. Parents usually expect it, and there is no question that this is often done. Studies show that 70 percent of sore throats are treated with antibiotics whereas only about a third of these can be expected to be caused by Group A Streptococcus. This practice is not recommended by treatment guidelines of the Infectious Diseases Society of America.
Overuse and misuse of antibiotics leads to the development of antibiotic-resistant bacterial strains that can reduce the patient’s own later immunity and put seriously ill persons at risk of illness that gets out of control. The 2012 update to treatment guidelines strongly stresses the need to confirm a diagnosis and not rely on clinical suspicion.
The gold standard for confirming a diagnosis is a throat culture, rubbing a sterile swab over the back of the throat and the tonsils. While not painful, this can be uncomfortable and treatment may be delayed as long as two days while the culture is grown and tested.
The rapid antigen test can detect strep bacteria within minutes but it is less sensitive and specific than the throat culture and, as a result, may miss some infections. If results come back negative, many doctors rely on the throat culture as a backup for confirmation...but only for some patients.
These tests are not usually recommended for children younger than three since strep infections are rare in this age group nor for adults since they have a low risk of serious complications.
Even without treatment, strep throat will usually resolve on its own in a few days. Use of antibiotics shortens the illness by a day or less. The primary reason to prescribe them is to lessen the risk of serious complications.
For patients with a confirmed infection with Group A Streptococcus and a risk of complications, the guidelines call for use of antibiotics–usually a 10-day course of either Penicillin V or amoxicillin. For persons without allergies to them, these medications are inexpensive, safe and effective. Increasing resistance to strep has been found in some of the more expensive broader spectrum antibiotics.
It’s crucial that the patient take the full course of antibiotics, even after the symptoms get better. Failure to complete the course might lead to recurrence and yet another risk of antibiotic resistance.
In addition to making you feel better sooner, antibiotics also shorten the time you are contagious and capable of passing the disease to other persons or to other parts of your body. Once established, strep can spread to the tonsils, sinuses, skin or middle ear.
You start being contagious even before symptoms appear and continue to be so for the first 24 hours after antibiotic therapy is started.
You’ll also feel better through use of over-the-counter medications such as ibuprofen (Advil, Motrin) and acetaminophen (Tylenol). Aspirin should not be given to anyone under age 18 because of the risk of Reye Syndrome.
The patient is also advised to:
• get plenty of rest;
• drink fluids to avoid dehydration and keep the sore throat lubricated;
• eat foods that are easy on the throat;
• gargle with warm salt water;
• use a humidifier, and
• stay away from irritants such as cigarette smoke and fumes from paint or cleaning products.
The disease can be spread through airborne droplets after a cough or sneeze, through use of shared utensils or cups or touching a door knob or another object that an infected person has touched.
As with all infections, the best way to protect yourself and others is to wash your hands frequently and thoroughly. You should also cover your mouth when you cough or sneeze and avoid sharing food, glasses and utensils.
General recommendations include throwing away the patient’s toothbrush once antibiotics have been started and he or she is no longer contagious. Microorganisms are more likely to flourish on damp as opposed to dry surfaces. On the other hand, a recent study found that while common mouth bacteria grew on all of the toothbrushes studied, strep could be found on only one brush, that of a child who did not have strep but was undoubtedly a carrier.
Many children and even some adults carry a colony of Group A Streptococcus bacteria in their throats without becoming sick. Should these carriers also develop a cold and come to a doctor seeking antibiotics, they might well test positive on either a rapid antigen test or a throat culture. But they do not have strep throat and should not be prescribed antibiotics, according to guidelines, since they are unlikely to be infectious or develop complications.
Decisions regarding strep throat and its treatment revolve mainly around the potential risk of complications rather than the sore throat itself.
REFERENCES:
Laurie Barclay, “Management of strep pharyngitis differs in adults and children,” Medscape Medical News, April 6, 2004 (JAMA, 2004;291:1587-1595).
Kerry Grens, “Back-up strep throat cultures may be unnecessary,” Reuters Health, October 23, 2012 (Journal of General Internal Medicine, 2012).
Mayo Clinic Staff, “Strep throat,” MayoClinic.com, December 20, 2012.
John Mersch, MD, FAAP, William C. Shiel, Jr., MD, FACP, FACR, and Mellissa Conrad Stoppler, M.D., “Strep throat (symptoms, causes, diagnosis and treatment,” MedicineNet, November 13, 2012.
Lisa Nainngolan, “AHA updates advice on strep throat, preventing rheumatic fever,” Heartwire, March 6, 2009.
Laurie Scudder, DNP, NP and Stanford T. Shulman, M.D., “Getting strep pharyngitis right,” Medscape Infectious Diseases, November 9, 2012.
Alexandra Sifferlin, “Strep throat? Don’t toss the toothbrush,” TIME Healthland, May 6, 2013.
“Strep throat,” KidsHealth, reviewed by Elana Pearl Ben-Joseph, M.D., October, 2011.
“Strep throat,” MedlinePlus, updated January 8, 2012.
“Strep throat–topic overview,” WebMD Medical References from Healthwise, July 27, 2010.
Yael Waknine, “Sore throats mostly viral, not strep,” Medscape Medical News, September 17, 2012.
10/22/2013
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