Complications from strep throat

What are complications of streptococcal pharyngitis (sore throat)?

  1. Alcaide AL, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2006. 21:449-469.

  2. Twefik TL, Al Garni M. Tonsillopharyngitis: Clinical highlights. J of Otolaryngology. 2005. 34:

  3. Mostov PD. Treating the immunocompetent patient who presents with an upper respiratory infection: pharyngitis, sinusitis, and bronchitis. Prim Care. 2007 Mar. 34(1):39-58. .

  4. Pichichero ME, Casey JR. Systematic review of factors contributing to penicillin treatment failure in Streptococcus pyogenes pharyngitis. Otolaryngol Head Neck Surg. 2007 Dec. 137(6):851-857. .

  5. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009 Mar 24. 119(11):1541-51. .

  6. Centers for Disease Control and Prevention. Summary of notifiable diseases, United States, 1997. MMWR Morb Mortal Wkly Rep. 1998 Nov 20. 46(54):ii-vii, 3-87. .

  7. Kalra MG, Higgins KE, Perez ED. Common Questions About Streptococcal Pharyngitis. Am Fam Physician. 2016 Jul 1. 94 (1):24-31. .

  8. Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr. 2012 Mar. 160(3):487-493.e3. .

  9. Centor RM, Allison JJ, Cohen SJ. Pharyngitis management: defining the controversy. J Gen Intern Med. 2007 Jan. 22(1):127-30. .

  10. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012 Nov 15. 55(10):1279-82. .

  11. Wagner FP, Mathiason MA. Using centor criteria to diagnose streptococcal pharyngitis. Nurse Pract. 2008 Sep. 33(9):10-2. .

  12. McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ. 2000 Oct 3. 163 (7):811-5. .

  13. Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012 Jun 11. 172 (11):847-52. . .

  14. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. 2005 Jun. 52(3):729-47, vi. .

  15. Lemierre’s syndrome, reemergence of a forgotten disease: a case report. Cases J. 2009 Mar 10. 2:6397. . .

  16. Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics. 2009 Feb. 123(2):437-44. .

  17. Cohen JF, Cohen R, Bidet P, et al. Efficiency of a clinical prediction model for selective rapid testing in children with pharyngitis: A prospective, multicenter study. PLoS One. 2017. 12 (2):e0172871. . .

  18. Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev. 2004 Jul. 17 (3):571-80, table of contents. .

  19. Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics. 2009 Feb. 123 (2):437-44. .

  20. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2006 Oct 18. CD000023. .

  21. Nakhoul GN, Hickner J. Management of adults with acute streptococcal pharyngitis: minimal value for backup strep testing and overuse of antibiotics. J Gen Intern Med. 2013 Jun. 28 (6):830-4. .

  22. Ayanruoh S, Waseem M, Quee F, Humphrey A, Reynolds T. Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department. Pediatr Emerg Care. 2009 Nov. 25(11):748-50. .

  23. Pelucchi C, Grigoryan L, Galeone C, Esposito S, Huovinen P, Little P, et al. Guideline for the management of acute sore throat. Clin Microbiol Infect. 2012 Apr. 18 Suppl 1:1-28. .

  24. Patel NN, Patel DN. Acute exudative tonsillitis. Am J Med. 2009 Jan. 122(1):18-20. .

  25. Cohen JF, Cohen R, Levy C, et al. Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective multicentre external validation study. CMAJ. 2015 Jan 6. 187(1):23-32. . .

  26. Chiappini E, Bortone B, Di Mauro G, et al. Choosing Wisely: The Top-5 Recommendations from the Italian Panel of the National Guidelines for the Management of Acute Pharyngitis in Children. Clin Ther. 2017 Mar. 39 (3):646-9. .

  27. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Review). The Cochrane Collaboration. 2007. (1):1-41.

  28. Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012 Oct 17. 10:CD008268. .

  29. Tasar A, Yanturali S, Topacoglu H, Ersoy G, Unverir P, Sarikaya S. Clinical efficacy of dexamethasone for acute exudative pharyngitis. J Emerg Med. 2008 Nov. 35(4):363-7. .

  30. Shephard A, Smith G, Aspley S, et al. Randomised, double-blind, placebo-controlled studies on flurbiprofen 8.75 mg lozenges in patients with/without group A or C streptococcal throat infection, with an assessment of clinicians’ prediction of ‘strep throat’. Int J Clin Pract. 2015 Jan. 69(1):59-71. .

  31. Muller D, Lindemann T, Shah-Hosseini K, et al. Efficacy and tolerability of an ectoine mouth and throat spray compared with those of saline lozenges in the treatment of acute pharyngitis and/or laryngitis: a prospective, controlled, observational clinical trial. Eur Arch Otorhinolaryngol. 2016 Apr 28. .

  32. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016 May 3. 315 (17):1864-73. .

  33. Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA. 2001 Sep 12. 286 (10):1181-6. .

  34. Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997-2010. JAMA Intern Med. 2014 Jan. 174 (1):138-40. .

  35. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. 2007 Sep-Oct. 5(5):436-43. .

  36. Van Howe RS, Kusnier LP 2nd. Diagnosis and management of pharyngitis in a pediatric population based on cost-effectiveness and projected health outcomes. Pediatrics. 2006 Mar. 117(3):609-19. .

  37. Pichichero ME. Pathogen shifts and changing cure rates for otitis media and tonsillopharyngitis. Clin Pediatr (Phila). 2006 Jul. 45(6):493-502. .

  38. Pichichero M, Casey J. Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis. Eur J Clin Microbiol Infect Dis. 2006 Jun. 25(6):354-64. .

  39. Brook I. Overcoming penicillin failures in the treatment of Group A streptococcal pharyngo-tonsillitis. Int J Pediatr Otorhinolaryngol. 2007 Oct. 71(10):1501-8. .

  40. Logan LK, McAuley JB, Shulman ST. Macrolide treatment failure in streptococcal pharyngitis resulting in acute rheumatic fever. Pediatrics. 2012 Mar. 129(3):e798-802. .

  41. Depdham D, Rao S, Hitchcock K. Should you treat carriers of pharyngeal group A strep?. J Fam Pract. 2008. 57:

  42. Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. 2009 Jan 21. CD004872. .

  43. Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Ann Fam Med. 2010 Jan-Feb. 8(1):58-63. . .

  44. Hayward G, Thompson M, Heneghan C, Perera R, Del Mar C, Glasziou P. Corticosteroids for pain relief in sore throat: systematic review and meta-analysis. BMJ. 2009 Aug 6. 339:b2976. . .

  45. Wing A, Villa-Roel C, Yeh B, Eskin B, Buckingham J, Rowe BH. Effectiveness of Corticosteroid Treatment in Acute Pharyngitis: A Systematic Review of the Literature. Acad Emerg Med. 2010. 17(5):476-483.

  46. Boggs W. What antibiotic strategy is best for adults with acute sore throat? Medscape Medical News. January 27, 2014; Accessed February 4, 2014. Available at http://www.medscape.com/viewarticle/820008.

  47. Huttner B. Antibiotic prescription for sore throat or the legacy of Mr X2.. Lancet Infect Dis. 2014 Jan 16. .

  48. Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Delaney B, et al. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis. 2014 Jan 16. .

  49. Nishiyama M, Morioka I, Taniguchi-Ikeda M, et al. Clinical features predicting group A streptococcal pharyngitis in a Japanese paediatric primary emergency medical centre. J Int Med Res. 2018 Jan 1. 300060517752954. . .

  50. Banigo A, Moinie A, Bleach N, Chand M, Chalker V, Lamagni T. Have reducing tonsillectomy rates in England led to increasing incidence of invasive Group A Streptococcus infections in children?. Clin Otolaryngol. 2018 Mar 5. .

  51. Gottlieb M, Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. J Emerg Med. 2018 Mar 6. .

  52. Dingle TC, Abbott AN, Fang FC. Reflexive culture in adolescents and adults with group A streptococcal pharyngitis. Clin Infect Dis. 2014 Sep 1. 59 (5):643-50. .

Pharyngitis (Strep Throat)

Many viruses and bacteria can cause acute pharyngitis. Streptococcus pyogenes, which are also called group A Streptococcus or group A strep, cause acute pharyngitis known as strep throat.

Etiology

Group A strep pharyngitis is an infection of the oropharynx caused by S. pyogenes. S. pyogenes are gram-positive cocci that grow in chains (see figure 1). They exhibit β-hemolysis (complete hemolysis) when grown on blood agar plates. They belong to group A in the Lancefield classification system for β-hemolytic Streptococcus, and thus are called group A streptococci.

Clinical Features

Group A strep pharyngitis is an acute pharyngitis that commonly presents with

  • Sudden-onset of sore throat
  • Odynophagia
  • Fever

Figure 1. Streptococcus pyogenes (group A Streptococcus) on Gram stain. Source: Public Health Image Library, CDC

Other symptoms may include headache, abdominal pain, nausea, and vomiting — especially among children. Patients with group A strep pharyngitis typically do not typically have cough, rhinorrhea, hoarseness, oral ulcers, or conjunctivitis. These symptoms strongly suggest a viral etiology.

On clinical examination, patients with group A strep pharyngitis usually have

  • Pharyngeal and tonsillar erythema
  • Tonsillar hypertrophy with or without exudates
  • Palatal petechiae
  • Anterior cervical lymphadenopathy

Patients with group A strep pharyngitis may also present with a scarlatiniform rash. The resulting syndrome is called scarlet fever or scarlatina.

Respiratory disease caused by group A strep infection in children younger than 3 years old rarely manifests as acute pharyngitis. These children usually have mucopurulent rhinitis followed by fever, irritability, and anorexia (called “streptococcal fever” or “streptococcosis”). In contrast to typical acute group A strep pharyngitis, this presentation in young children is subacute and high fever is rare.

Transmission

Group A strep pharyngitis is most commonly spread through direct person-to-person transmission. Typically transmission occurs through saliva or nasal secretions from an infected person. People with group A strep pharyngitis are much more likely to transmit the bacteria to others than asymptomatic pharyngeal carriers. Crowded conditions — such as those in schools, daycare centers, or military training facilities — facilitate transmission. Although rare, spread of group A strep infections may also occur via food. Foodborne outbreaks of pharyngitis have occurred due to improper food handling. Fomites, such as household items like plates or toys, are very unlikely to spread these bacteria.

Humans are the primary reservoir for group A strep. There is no evidence to indicate that pets can transmit the bacteria to humans.

Treatment with an appropriate antibiotic for 24 hours or longer generally eliminates a person’s ability to transmit group A strep. People with group A strep pharyngitis or scarlet fever should stay home from work, school, or daycare until:

  • They are afebrile
    AND
  • 24 hours after starting appropriate antibiotic therapy

Incubation Period

The incubation period of group A strep pharyngitis is approximately 2 to 5 days.

Risk Factors

Group A strep pharyngitis can occur in people of all ages. It is most common among children 5 through 15 years of age. It is rare in children younger than 3 years of age.

The most common risk factor is close contact with another person with group A strep pharyngitis. Adults at increased risk for group A strep pharyngitis include:

  • Parents of school-aged children
  • Adults who are often in contact with children

Crowding, such as found in schools, military barracks, and daycare centers, increases the risk of disease spread.

Diagnosis and Testing

Viruses Cause Most Pharyngitis

Group A Streptococcus causes:

  • 20% to 30% of sore throats in children
  • 5% to 15% of sore throats in adults

The differential diagnosis of acute pharyngitis includes multiple viral and bacterial pathogens. Viruses are the most common cause of pharyngitis in all age groups. Experts estimate that group A strep, the most common bacterial cause, causes 20% to 30% of pharyngitis episodes in children. In comparison, experts estimate it causes approximately 5% to 15% of pharyngitis infections in adults.

History and clinical examination can be used to diagnose viral pharyngitis when clear viral symptoms are present. Viral symptoms include:

  • Cough
  • Rhinorrhea
  • Hoarseness
  • Oral ulcers
  • Conjunctivitis

Patients with clear viral symptoms do not need testing for group A strep. However, clinicians cannot use clinical examination to differentiate viral and group A strep pharyngitis in the absence of viral symptoms.

Clinicians need to use either a rapid antigen detection test (RADT) or throat culture to confirm group A strep pharyngitis. RADTs have high specificity for group A strep but varying sensitivities when compared to throat culture. Throat culture is the gold standard diagnostic test.

See the resources section for specific diagnosis guidelines for adult and pediatric patients1,2,3.

Special Considerations

Clinicians should confirm group A strep pharyngitis in children older than 3 years of age to appropriately guide treatment decisions. Giving antibiotics to children with confirmed group A strep pharyngitis can reduce their risk of developing sequela (acute rheumatic fever). Testing for group A strep pharyngitis is not routinely indicated for:

  • Children younger than 3 years of age
  • Adults

Acute rheumatic fever is very rare in those age groups.

Clinicians can use a positive RADT as confirmation of group A strep pharyngitis in children. However, clinicians should follow up a negative RADT in a child with symptoms of pharyngitis with a throat culture. Clinicians should have a mechanism to contact the family and initiate antibiotics if the back-up throat culture is positive.

Treatment

The use of a recommended antibiotic regimen to treat group A strep pharyngitis:

  • Shortens the duration of symptoms
  • Reduces the likelihood of transmission to family members, classmates, and other close contacts
  • Prevents the development of complications, including acute rheumatic fever

When left untreated, the symptoms of group A strep pharyngitis are usually self-limited. However, acute rheumatic fever and suppurative complications (e.g., peritonsillar abscess, mastoiditis) are more likely to occur after an untreated infection. Patients, regardless of age, who have a positive RADT or throat culture need antibiotics. Clinicians should not treat viral pharyngitis with antibiotics.

Penicillin or amoxicillin is the antibiotic of choice to treat group A strep pharyngitis. There has never been a report of a clinical isolate of group A strep that is resistant to penicillin. However, resistance to azithromycin and clarithromycin is common in some communities. For patients with a penicillin allergy, recommended regimens include narrow-spectrum cephalosporins (cephalexin, cefadroxil), clindamycin, azithromycin, and clarithromycin.

See the resources section for specific treatment guidelines for adult and pediatric patients1,2,3.

Table: Antibiotic Regimens Recommended for Group A Streptococcal Pharyngitis

Table: Antibiotic Regimens Recommended for Group A Streptococcal Pharyngitis

Drug, Route Dose or Dosage Duration or Quantity
For individuals without penicillin allergy
Penicillin V, oral Children: 250 mg twice daily or 3 times daily; adolescents and adults: 250 mg 4 times daily or 500 mg twice daily 10 days
Amoxicillin, oral 50 mg/kg once daily (max = 1000 mg); alternate:
25 mg/kg (max = 500 mg) twice daily
10 days
Benzathine penicillin G, intramuscular <27 kg: 600 000 U; ≥27 kg: 1 200 000 U 1 dose
For individuals with penicillin allergy
Cephalexin,a oral 20 mg/kg/dose twice daily (max = 500 mg/dose) 10 days
Cefadroxil,a oral 30 mg/kg once daily (max = 1 g) 10 days
Clindamycin, oral 7 mg/kg/dose 3 times daily (max = 300 mg/dose) 10 days
Azithromycin,b oral 12 mg/kg once (max = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days 5 days
Clarithromycinb, oral 7.5 mg/kg/dose twice daily (max = 250 mg/dose) 10 days

Abbreviation: Max, maximum.
a Avoid in individuals with immediate type hypersensitivity to penicillin.
b Resistance of group A strep to these agents is well-known and varies geographically and temporally.

From: Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of AmericaExternal. Clin Infect Dis. 2012;55(10):e86–e102, Table 2 (adapted) and it’s erratumExternal (Clin Infect Dis. 2014;58(10):1496).

Note: If you are interested in reusing this table, first obtain permission from the journal; request by emailing [email protected]

Carriage

Asymptomatic group A strep carriers usually do not require treatment. Carriers have positive throat cultures or are RADT positive, but do not have clinical symptoms or an immunologic response to group A strep antigens on laboratory testing. Compared to people with symptomatic pharyngitis, carriers are much less likely to transmit group A strep to others. Carriers are also very unlikely to develop suppurative or nonsuppurative complications.

Some people with recurrent episodes of acute pharyngitis with evidence of group A strep by RADT or throat culture actually have recurrent episodes of viral pharyngitis with concurrent streptococcal carriage. Repeated use of antibiotics among this subset of patients is unnecessary. However, identifying carriers clinically or by laboratory methods can be very difficult. The Infectious Diseases Society of America guidelines and Red Book address determining someone if is a carrier and their management.1, 2

Prognosis and Complications

Rarely, suppurative and nonsuppurative complications can occur after group A strep pharyngitis. Suppurative complications result from the spread of group A strep from the pharynx to adjacent structures. They can include:

  • Peritonsillar abscess
  • Retropharyngeal abscess
  • Cervical lymphadenitis
  • Mastoiditis

Other focal infections or sepsis are even less common.

Acute rheumatic fever is a nonsuppurative sequelae of group A strep pharyngitis. Post-streptococcal glomerulonephritis is a nonsuppurative sequelae of group A strep pharyngitis or skin infections. These complications occur after the original infection resolves and involve sites distant to the initial group A strep infection site. They are thought to be the result of the immune response and not of direct group A strep infection.

Prevention

Good hand hygiene and respiratory etiquette can reduce the spread of all types of group A strep infection. Hand hygiene is especially important after coughing and sneezing and before preparing foods or eating. Good respiratory etiquette involves covering your cough or sneeze. Treating an infected person with an antibiotic for 24 hours or longer generally eliminates their ability to transmit the bacteria. Thus, people with group A strep pharyngitis should stay home from work, school, or daycare until:

  • They are afebrile
    AND
  • At least 24 hours after starting appropriate antibiotic therapy

Epidemiology and Surveillance

Humans are the only reservoir for group A strep. It is most common among children 5 through 15 years of age. It is rare in children younger than 3 years of age. In the United States, group A strep pharyngitis is most common during the winter and spring.

CDC does not track the incidence of group A strep pharyngitis or other non-invasive group A strep infections. CDC tracks invasive group A strep infections through the Active Bacterial Core surveillance (ABCs) program. For information on the incidence of invasive group A strep infections, please visit the ABCs Surveillance Reports website.

Resources

  1. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of AmericaExternal. Clin Infect Dis. 2012;55(10):1279–82.
  2. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, et al. Erratum to clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of AmericaExternal. Clin Infect Dis. 2014;58(10):1496.
  3. Committee on Infectious Diseases. Group A streptococcal infectionsExternal. In Kimberlin DW, Brady MT, Jackson MA, Long SS, editors. 30th ed. Red Book: 2015 Report of the Committee on Infectious Diseases. Elk Grove Village (IL): American Academy of Pediatrics; 2015:732–44.
  4. Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: A scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Academy of PediatricsExternal. Circulation. 2009;119(11):1541–51.

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How to Deal With Strep Throat Complications and Prevention Strategies

Aside from causing a fever, rheumatic fever can cause nosebleeds, abdominal pain, and heart problems that may lead to shortness of breath or chest pain. It can also cause potentially painful swelling in your knees, ankles, elbows, or wrists, which sometimes leads to abnormal body movement. (5)

Dr. Rajapakse notes that rheumatic fever was once a leading cause of heart valve disease among children in the United States, but this is no longer the case.

“Thankfully now in the United States and other resource-rich countries, we don’t see rheumatic fever very often,” she adds.

PANDAS This name is short for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. It most often refers to obsessive compulsive disorder (OCD) or a tic disorder that first appears, or suddenly worsens, soon after a strep infection.

Symptoms of PANDAS may include tics (uncontrollable movements or vocalizations), obsessive or compulsive thoughts and behaviors, increased irritability, and anxiety attacks.

PANDAS typically appears between age 3 and puberty, and it rarely develops after age 12. (6)

Ways to Prevent Strep Throat

The best way to avoid the discomfort of strep throat, of course, is to avoid it altogether.

There are several steps you can take to help prevent a strep infection:

  • Wash your hands frequently. Regular handwashing ensures that any strep bacteria you are exposed to are less likely to reach your nose or mouth.
  • Dispose of used tissues promptly. This is especially true if you or your child aren’t feeling well, but it’s never a good idea to have used tissues lying around.
  • Cover your mouth when coughing or sneezing. Strep throat is spread through contact with respiratory secretions, and covering a cough or sneeze can prevent these secretions form being sprayed into the air. It’s best to cough or sneeze into your elbow or a tissue, since getting respiratory secretions on your hands and touching objects can also spread the bacteria.
  • Avoid direct contact with anyone with strep throat. If you have more than one child and one has strep throat, it’s best to keep them mostly apart until antibiotics start to take effect.
  • Don’t share cups or utensils. This is a good rule to follow in general, but it’s especially important if someone isn’t feeling well.
  • Take the full 10-day course of antibiotics. This is the best way to ensure that your infection doesn’t return, potentially infecting other people in the process. (7)

PMC

Group A Streptococcus (GAS) is the most common cause of acute bacterial pharyngitis, accounting for 20-30% of episodes of pharyngitis in children and 5-15% in adults.1 Streptococcal pharyngitis is a benign illness; however, it can be associated with suppurative tonsillopharyngeal complications or non-suppurative immune mediated complications such as acute rheumatic fever (ARF), rheumatic heart disease (RHD), and poststreptococcal glomerulonephritis. Other nonsuppurative post-streptococcal sequelae include streptococcal toxic shock syndrome, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS), poststreptococcal autoimmune dystonia secondary to striatal necrosis, poststreptococcal reactive arthritis, and Sydenham’s chorea and other autoimmune movement disorders. Although the exact relationship between streptococcal pharyngitis and rheumatic fever is not totally clear, failure to eradicate the organism from the pharynx has been identified as a significant risk factor. The incidence of RHD is considerably higher in countries where aggressive treatment with effective antibiotics is not always available or undertaken. The asymptomatic carrier rate for GAS is up to 20%;1 therefore, treating all sore throat with antibiotics will remain questionable. In an open study of prescribing strategy in over 700 patients with sore throat randomized to antibiotic versus no prescription versus delayed prescription for 3 days, Little et al2 found no difference in duration of illness, proportion of patients better by day 3, days missed from work or school, or proportion of patients satisfied with treatment.2 The Centor clinical prediction score can be used to assist the decision on whether to prescribe an antibiotic, but cannot be relied upon for a precise diagnosis.3 More recently, a 5-item FeverPAIN (fever, purulence, attend rapidly, inflamed tonsils, no cough, or coryza) clinical score has been proposed, which has been shown to reduce the use of antibiotics by 30% without worsening other outcomes, costs, and antibiotic resistance.4 In the USA, the wide use of rapid antigen diagnostic tests for GAS inform the clinical decision on the management of pharyngitis without requiring culture results, improving opportunities for the primary prevention of ARF. However, culture back up and sensitivity results are required when non-beta-lactam antimicrobial agents are used to confirm sensitivity. Although these point-of-care antigen tests are promising, concerns on the sensitivity and specificity, and variation between test methodologies have limited their clinical use. The standard management of GAS pharyngitis is 10 days of oral penicillin V or a single dose of benzathine penicillin G given intramuscularly.1 Amoxicillin is often used for increased palatability and compliance. However, ampicillin-based antibiotics, including co-amoxiclav, may cause a rash when used in the presence of glandular fever. In nonanaphylactic cases of penicillin allergy, a first-generation cephalosporin is recommended.1 For individuals with severe penicillin allergy, alternative therapy includes macrolide or azalide antibiotics, which include erythromycin, clarithromycin, and azithromycin, or possibly clindamycin. All recommended oral treatment courses extend for 10 days except for azithromycin, for which a 3-5-day treatment course is recommended due to its long half-life. The short course and the once-daily dosing of azithromycin may lead clinicians to prescribe azithromycin for patients who have no clear contraindication to penicillin or cephalosporin. Unfortunately, the increased incidence of macrolide-resistant GAS has limited utility of azithromycin for the treatment of Streptococcal pharyngitis. The growth in rates of resistance correlates with increased macrolide utilization. Worldwide macrolide resistance (MR) has ranged from 1.1-98%, indicating that surveillance data are of paramount importance to inform the clinical decision for the treatment of Streptococcal pharyngitis in a given population. Recently, a scarlet fever outbreak in China and Hong Kong has been associated with MR.5 Variation in MR rates has been attributed to several factors, including horizontal gene transfer and spread of dominant resistance clones, overconsumption of macrolide antibiotics, and temporal variation in the distribution of emm types. Although all GAS are universally sensitive to beta-lactam antibiotics, MR in GAS has been described since the 1950s. Resistance to macrolides in GAS arises by 2 distinct mechanisms: (i) active drug efflux via a transmembrane pump encoded by mef genes and (ii) ribosomal modification by Erm methylase. The later confers cross-resistance to macrolides, lincosamides, and streptogramins (MLSB phenotype). Clinical significant MR was well documented in several countries in the 1970s, which was correlated with a massive increase in macrolide consumption. In Saudi Arabia, it has been reported that 6.3% of the 335 GAS collected from hospital laboratories in 5 different geographical areas during 2003 were resistant to macrolide.6 Figure 1 shows the epidemiology of MR in GAS in the population served by our institution over a 9-year period. Overall, a total of 578 consecutive isolates of GAS recovered from throat swab specimens (non-duplicate) were tested in our microbiology laboratory during the study period. Susceptibility tests were performed by an automated system (BD Phoenix, Riyadh, Saudi Arabia) or disk diffusion method following the recommendation by the Clinical and Laboratory Standard Institute. Results have shown increasing MR rates from an average of 4.5% between 2006 and 2009 to an average of 12% between 2010 and 2014. During 2014, MR increased to 23.4%, which highlights the need for continued surveillance. These data also indicate the importance of taking swabs to confirm sensitivity when using azithromycin to treat sore throat and to allow monitoring of resistance.

Erythromycin susceptibility among Group A beta-hemolytic Streptococci at Qatif Central Hospital, Qatif, Saudi Arabia.

In view of the antibiotic resistance crisis and in line with antibiotic stewardship programs, unnecessary prescribing of antibiotics for minor viral self-limiting illness should be avoided. The use of azithromycin in the management of GAS pharyngitis is considered to be a third-line therapy and should be limited to patients with severe penicillin allergy. If azithromycin must be used to treat streptococcal pharyngitis, culture and susceptibility testing should be performed to avoid clinical or microbiological treatment failure.

National Collaborating Centre for Infectious Diseases

Cause and Pathogenesis

Group A streptococcus (GAS) bacteria is a Gram positive, beta-hemolytic coccus in chains. It is responsible for a range of diseases in humans. These diseases include strep throat (acute pharyngitis) and skin and soft tissue infections such impetigo and cellulitis. These can also include rare cases of invasive (serious) illnesses such as necrotizing fasciitis (flesh eating disease) and toxic shock syndrome (TSS). Several virulence factors contribute to the pathogenesis of GAS, such as M protein, hemolysins, and extracellular enzymes.

CDC- Group A Streptococcal Disease – For Clinicians

PHAC- Pathogen Safety Data Sheet- Streptococcus pyogenes (Group A Strep)

Signs and symptoms

Signs and symptoms of GAS infections will vary based on the disease the infection causes.

Strep throat: Symptoms may include a swollen red sore throat and tonsil (pharyngeal and tonsillar erythema), tonsillar hypertrophy with or without exudates, palatal petechiae (uncommon but highly specific finding), high fever, headache, and swollen lymph nodes in the neck (anterior cervical lymphadenopathy). Abdominal pain, nausea, and vomiting might be present especially among children.

Cough, rhinorrhea, hoarseness, oral ulcers, and conjunctivitis are not typically seen in patients with group A strep pharyngitis and are therefore strongly suggestive of a viral etiology.

CDC-Group A Streptococcal Disease – For Clinicians

CDC-Group A Streptococcal Disease-Pharyngitis

Mayo Clinic- Strep Throat – written for patients and the general public

Scarlet fever: Infected individuals may experience a quickly spreading red rash (erythematous rash that blanches on pressure) that feels like sandpaper on the body. The rush begins on the trunk, then spreads outward, usually sparing the palms, soles, and face but accentuates in flexor creases (i.e., under the arm, in the groin), termed “Pastia’s lines”. They may also have red swollen lips and red spots on the tongue (red papillae). Circumoral pallor and strawberry tongue may be present as the disease resolves.

Scarlett fever usually occurs with acute pharyngitis although it can also follow group A strep pyoderma or wound infections.

CDC-Group A Streptococcal Disease – For Clinicians

CDC-Group A Streptococcal Disease – Scarlet Fever

Mayo Clinic- Scarlet Fever – written for patients and the general public

Impetigo: Symptoms may include a red skin rash that looks like a group of small blisters or red bumps. When the blisters burst and fluid seeps out, the fluid dries and the blisters become coated with a yellow or grey crust. The sores usually occur around the nose and mouth but can be spread to other areas of the body by fingers, clothing and towels. Itching and soreness are generally mild.

A less common form of the disorder, called bullous impetigo, may feature larger blisters that occur on the trunk of infants and young children. A more serious form of impetigo, called ecthyma, penetrates deeper into the skin — causing painful fluid- or pus-filled sores that turn into deep ulcers.

Mayo Clinic- Impetigo – written for patients and the general public

Invasive Group A Streptococcus Infections: May present as any of several clinical syndromes, including pneumonia, bacteremia in association with cutaneous infection (e.g., cellulitis, erysipelas, or infection of a surgical or non-surgical wound), deep soft tissue infection (e.g., myositis or necrotizing fasciitis), meningitis, peritonitis, osteomyelitis, septic arthritis, postpartum sepsis (i.e., puerperal fever), neonatal sepsis, STSS or nonfocal bacteremia. Skin and soft tissue infections tend to be the most common invasive GAS manifestations.

Toxic shock syndrome: Streptococcal TSS results in a rapid drop in blood pressure and organ failure. Symptoms may include fever, redness of the skin, dizziness, influenza-like symptoms, confusion, shock, diarrhoea, vomiting and severe muscle pain. This disease is the most serious manifestation of invasive GAS disease.

Mayo Clinic- Toxic Shock Syndrome – written for patients and the general public

Necrotizing Fasciitis (NF) with or without Necrotizing Myositis (NM) is present in about 50 per cent of patients with STSS.

Necrotizing Fasciitis (sometimes called “the flesh-eating bacteria”): NF is a deep-seated infection of the subcutaneous tissue that results in rapid destruction of fascia and fat, but may spare the skin itself. Symptoms may include fever and intense pain, redness and swelling in the affected area. Often the pain is disproportionate to (much worse than) the appearance of the infection.

Necrotizing Myositis occurs in patients with NF and STSS.

Severity and Complications

The group A streptococcal infections can range from mild and uncomplicated such as acute GAS pharyngitis to life threating invasive GAS infections such as STSS.

PHAC- Pathogen Safety Data Sheet- Streptococcus pyogenes (Group A Strep)

There are Pus-Forming (Suppurative) Complications and inflammatory (nonsupprative) complications of untreated Group A Streptococcal infections such as Strep Throat Strep or scarlet fever.

Suppurative Sequelae

The 3 most common pus-forming complications that can occur from untreated strep throat include: peritonsillar or retropharyngeal abscess, otitis media, and sinusitis. Other less common complications that result from the formation of pus include infections that spread to the blood, spinal cord, brain, and muscle sheaths. These complications can also be life-threatening if not treated appropriately.

Nonsuppurative sequelae

Post-Streptococcal Glomerulonephritis: is a kidney disease that can develop as a result of the immune system fighting off the group A strep throat or skin such as strep throat, scarlet fever, and impetigo. It usually takes about 10 days after strep throat or scarlet fever and about 3 weeks after a group A strep skin infection for PSGN to develop.

Symptoms of PSGN can include: dark, reddish-brown urine, swelling (edema), especially in the face, around the eyes, and in the hands and feet, decreased need to pee or decreased amount of urine, feeling tired due to low iron levels in the blood (fatigue due to mild anemia). In addition, someone with PSGN usually has protein in the urine and high blood pressure (hypertension).

Some people may have no symptoms or symptoms that are so mild that they don’t seek medical help.

CDC-Group A Streptococcal Diseases – Post-Streptococcal Glomerulonephritis

CDC – Complications – Post- Streptococcal Glomerulonephritis – For Clinicians

Rheumatic fever: is an inflammatory disease that can develop as a complication of inadequately treated strep throat or scarlet fever. Rheumatic fever can cause permanent damage to the heart, including damaged heart valves and heart failure. Rheumatic fever symptoms vary ranging from few symptoms or several, and symptoms do not all appear simultaneously and can change during the course of the disease. The onset of rheumatic fever usually occurs about two to four weeks after a strep throat infection.

The signs and symptoms of rheumatic fever (inflammation in the heart, joints, skin or central nervous system) can include:

Fever; painful, red, hot, swollen and tender joints – most often in the knees, ankles, elbows and wrists, pain might migrate from one joint to another; small, painless bumps (nodules) beneath the skin, flat or slightly raised, painless rash with a ragged edge (erythema marginatum), chest pain, heart murmur, fatigue; jerky, uncontrollable body movements (Sydenham chorea, or St. Vitus’ dance) – most often in the hands, feet and face, outbursts of unusual behavior, such as crying or inappropriate laughing, that accompanies Sydenham chorea.

The link between strep infection and rheumatic fever isn’t clear, but it appears that the bacterium tricks the immune system (molecular mimicry).

Mayo Clinic- Complications- Rheumatic Fever – written for patients and the general public

Incubation Period

The incubation period of group A strep infections is approximately 2 to 5 days.

PHAC- Pathogen Safety Data Sheet- Streptococcus pyogenes (Group A Strep)

CDC- Group A Streptococcal Disease – For Clinicians

Reservoir and Transmission

Human noses, throat and skin are the primary reservoirs for GAS and the bacteria is often carried without symptoms. These carriers are less contagious than symptomatic carriers of the bacteria. Infections in children are an important reservoir for infections in adults.

Transmission of GAS is through the air via respiratory droplets, such as coughs, sneezes, and nasal secretions. GAS can also spread from person to person through close contact such as kissing, sharing drinking cups, forks, spoons or cigarettes.

Crowded conditions — such as those in schools, daycare centers, or military training facilities — facilitate transmission.

Although rare, spread of group A strep infections may also occur via food. Foodborne outbreaks of group A strep have occurred due to improper food handling.

The portal of entry for invasive GAS infections is often the skin or soft tissue and infection may follow minor or unrecognized trauma without an obvious break in the skin.

CDC-Group A Streptococcal Disease- For Clinicians

Laboratory Diagnosis
The diagnosis of group A strep infections (pharyngitis) is confirmed by either a rapid antigen detection test (RADT) or a throat culture. The diagnosis of invasive GAS is based on the culture of GAS organisms from specimens taken from normally sterile body site.

In the case of NF a non-sterile wound sample might be taken.

RADTs have high specificity for group A strep but varying sensitivities when compared to throat culture. Throat culture is the gold standard diagnostic test. A negative RADT in a child with symptoms of scarlet fever should be followed up by a throat culture.

CDC-Group A Streptococcal (GAS) Disease – For Laboratorians

Prevention and Control

GAS spreads by contact with infected respiratory droplets or contact with items that might be contaminated with the saliva of an infected person. Measures that reduce the risk of transmission include:

– Good hand hygiene – wash hands often with soap and water, or use alcohol hand rub.

– Avoid sharing items that could be contaminated with saliva such as water bottles, drinking glasses, utensils, etc.

– Clean and disinfect high touch/potentially-contaminated surfaces.

– Cover coughs or sneezes with a tissue or a forearm.

– Stay home from work, school, or daycare until afebrile and until 24 hours after starting appropriate antibiotic therapy

-Employ harm reduction strategies among injection drug user population

The use of a recommended antibiotic regimen to treat group A streptococcus infections shortens the duration of symptoms; reduces the likelihood of transmission to family members, classmates, and other close contacts; and prevents the development of complications, including acute rheumatic fever.

PHAC-CCCR-Guidelines for the Prevention and Control of Invasive Group A Streptococcus

PHAC- Pathogen Safety Data Sheet- Streptococcus pyogenes (Group A Strep)

Vaccination

There is currently no vaccine to prevent group A strep infections, although several vaccines are in development.

CDC-Group A Strep Disease Outbreak Response

PHAC-Group A Strep-Vaccines ARCHIVED AND IS NOT BEING UPDATED

Antibiotic prophylaxis

Most people who are exposed to someone with a group A strep infection should not receive prophylaxis. However, in some situations, prophylaxis may be recommended for someone who is exposed to someone with an invasive group A strep infection (i.e., necrotizing fasciitis, streptococcal toxic shock syndrome).

CDC-Group A Strep Disease Outbreak Response

PHAC-Recommendations for Chemoprophylaxis ARCHIVED AND IS NOT BEING UPDATED

Treatment

Treatment will vary based on the disease a person has. Some diseases, such as strep throat, can heal on their own. Others, such as impetigo, may require the use of antibiotics to heal.

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; antibiotics are effective if given within 9 days of the onset of symptoms.

For invasive GAS infections, antibiotics, hospitalization and surgery may be required. Surgery is almost always required for necrotising fasciitis.

Penicillin or amoxicillin is the antibiotic of choice. There has never been a report of a clinical isolate of group A strep that is resistant to penicillin. For patients with a penicillin allergy, recommended regimens include narrow-spectrum cephalosporins (e.g., cephalexin, cefadroxil), clindamycin, azithromycin, and clarithromycin.

CDC- Group A Strep Disease- Treatment

Epidemiology

General

Different clinical manifestations of this bacterium are more common in different parts of the world. Streptococccal pharyngitis is predominant in temperate areas and peaks in late winter and early spring. Impetigo is more common in warm humid climates. School-aged children carry S. pyogenes in their throats and are more at risk of having the disease.

PHAC- Pathogen Safety Data Sheets: Infectious Substances – Streptococcus pyogenes

Canada:

Invasive GAS disease became nationally notifiable in January 2000. The most recent year for which complete national data have been published is 2001. The overall incidence of disease in 2001 was 2.7 per 100,000 population. The highest reported incidence rates occurred among adults 60 years of age (5.3 per 100,000), followed by children < 1 year of age (4.8 per 100,000) and children 1 to 4 years of age (3.6 per 100,000). Elevated rates of invasive GAS disease have been detected among Indigenous populations living in the Canadian Arctic through the population-based International Circumpolar Surveillance system. Between 2000 and 2002, no cases of invasive GAS disease were reported among non-Indigenous persons in the territories, northern Quebec or northern Labrador. In contrast, among Indigenous people living in northern Canada, the incidence rate of disease was 9.0 per 100,000 in 2000 (7 cases), 3.0 per 100,000 in 2001 (2 cases) and 5.0 per 100,000 in 2002 (4 cases).

PHAC-Epidemiology of Invasive GAS Disease in Canada

USA:

CDC-Surveillance reports

CDC-ABCs Report: Group A Streptococcus, 2015

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There are two different germs that cause sore throats: viruses and bacteria. Most sore throats are caused by viruses. The one that comes on suddenly is caused by bacteria (germs) called “strep,” short for streptococci (strep toe KAW ki). If untreated, it can lead to complications and be spread to others.

Strep throat is contagious (can be spread to others). The strep bacteria hang out in the nose and throat. When the infected person coughs, sneezes or talks, the germs go into the air. The germs are then breathed in or caught by touching something that the germs are on (contaminated). Strep throat is most common in school age children but anyone can be infected with strep.

Antibiotic medicine must be given as soon as possible to prevent the strep germs from spreading in the body. The bacteria can cause damage to the kidneys or to the heart (Rheumatic fever). Rheumatic fever can cause painful and swollen joints, a specific type of rash, or harm the heart.

There are some people with strep who should not be given antibiotics. Strep bacteria can sometimes live on children’s throats without causing illness. As many as 1 in 5 children are “strep carriers.” This means that they have no symptoms, they are not contagious and their throat strep test stays positive even after taking antibiotics. If your child gets a sore throat and you know that he or she is a strep carrier, the doctor will treat it like a virus.

Symptoms

A child with strep throat, may have some or all of these symptoms:

  • Sore throat, especially when swallowing
  • Bright red, swollen tonsils, sometimes with white patches or streaks of pus
  • “Strawberry” look to the tongue or tiny red spots on the back roof of the mouth
  • Fever
  • Swollen, tender glands in the neck
  • Headache, irritability or fussiness
  • Sleeping more than usual
  • Poor appetite, nausea or vomiting, especially in younger children
  • Pain in the abdomen (tummy)
  • A red rash on the body that “feels like sandpaper.” It may appear 12 to 48 hours after the first symptoms. This is known as scarlet fever or scarlatina.

When a child has a cough, hoarseness, red eyes and runny nose, it may be due to a virus, the flu or a different illness rather than strep.

Diagnosis

The health provider will examine your child, check for signs and symptoms and do a strep test.

A sample will be taken from the throat and tested. Two cotton-tipped swabs will be swiped over the back of the throat and tonsils. This should not hurt but may cause your child to gag. The lab will do one or more tests on the sample.

  • Rapid strep test screen (rapid antigen test): The test usually takes up to half an hour. You will be asked to wait until the test results are read. A “positive” test means your child has strep throat caused by bacteria. If the rapid strep test screen is negative and the doctor still suspects strep, a follow-up test will be done.
  • Second test to confirm the rapid strep test: Your child will not need another throat swab done for a follow-up test. The same sample will be tested in a different way to confirm the result of the rapid strep test. If the second test is positive, you will be notified the next day so that your child can be treated with antibiotics. A negative test means the sore throat is likely caused by a virus and does not need antibiotics.

Strep carriers do not need to have repeated strep tests done. Doing throat swabs on children who are strep carriers may cause them to take antibiotics that they do not need.

Treatment with Antibiotics

A positive strep test must be treated with antibiotic medicine within a few days to prevent the germs from causing problems. Antibiotics are not given to strep carriers or to treat viruses because and they will not be effective. Antibiotics can have side effects such as diarrhea and rash.

Antibiotic medicine is usually taken by mouth but may be given by injection. Your child should start feeling better within a day or two.

It is very important to take all the medicine for ten days, as ordered, even after starting to feel better (Picture 1). When antibiotics are not used correctly (such as taking too much, missing doses or not finishing a prescription), some bacteria can develop resistance. Resistance can make infections very hard to treat. Sometimes they cannot be treated at all.

If your child is allergic to penicillin, be sure to tell the doctor. Another medicine will be prescribed.

Comfort and Care

  • If your child has a fever or throat pain, give acetaminophen (such as Tylenol®) or ibuprofen (Advil®, Motrin®) as directed. Read the label to know the right dose for your child. Do not give aspirin or products that contain aspirin.
  • Give your child lots of liquids, such as water, Pedialyte®, apple juice or popsicles. Give small amounts of liquid often.
  • Give soft foods that are easy to swallow, such as applesauce, mashed potatoes, hot cereal or eggs. Your child may not want to eat much if it hurts to swallow.
  • To soothe a sore throat offer:
    • For children over age 1, warm fluids such as chicken broth or apple juice
    • For children over age 4, throat or cough lozenges or throat sprays. Read the label to know the right dose for your child. Do not use throat sprays that contain benzocaine, as this could cause a drug reaction.
    • For children over age 6 who are able to gargle without swallowing, a mixture of ½ teaspoon of table salt in 8 ounces of warm water. Swish and gargle the mixture 2 to 3 times a day for the next few days. Do not let your child swallow the salt water; have him spit it out.

How to Protect Others

  • Everyone should wash hands often with soap or hand sanitizer. Good handwashing prevents the spread of infection.
  • Cover the mouth when coughing or sneezing. Give your child a paper bag and have him put his used tissues in the bag. Moisture from the child’s nose and mouth is contagious.
  • Do not share drinking cups or eating utensils.
  • Throw away your child’s toothbrush and buy a new one as soon as the illness is over. (Strep throat germs may still be on your child’s toothbrush.)
  • Keep your child away from others for 24 hours after the medicine is started and until he has no fever.
  • Tell the school nurse and your child’s teacher that your child has strep throat. It is important for school personnel to know so that other parents can be told to watch for symptoms in their children.
  • If anyone in the family gets a sore throat, he should be checked by a doctor to see if medical treatment is needed.

When to Call the Doctor

Your child:

  • Has a fever more than 102˚F that lasts more than 2 days after taking an antibiotic
  • Has a sore throat that lasts more than 3 days after taking an antibiotic
  • Develops a rash or diarrhea after taking antibiotics
  • Starts drooling, cannot talk or voice becomes muffled

When to Return to School or Daycare

Your child should stay home from school or childcare until he has taken antibiotic medicine for 24 hours and has no fever.

Strep Throat – Bacterial (PDF)

HH-I-122 11/89, Revised 10/17 Copyright 1989, Nationwide Children’s Hospital

Strep throat

What is strep throat?

Strep throat is an infection caused by a bacteria (germ) called Group A Streptococcus. It is more common in children than adults.

What are the symptoms?

Not all sore throats are strep throat. Children with strep throat usually have:

  • a very sore throat,
  • trouble swallowing,
  • swollen and tender neck nodes, and
  • fever.

Your child may also complain of headache, nausea or a sore stomach.

Children with strep throat do not usually have cold symptoms (cough and runny nose).

How do children get strep throat?

Direct contact: When someone comes into contact with an infected person’s saliva (spit), nose or sore on the skin.

Indirect contact: When germs in the nose and throat of an infected person spread through the air—as droplets from a cough or sneeze.

How is it diagnosed?

Your doctor cannot diagnose strep throat just by looking at your child’s throat. He will have to take a throat swab. That means collecting a bit of fluid from the back and sides of your child’s throat, using a long cotton swab. The fluid is then tested for the strep bacteria.

How is it treated?

Although strep throat usually gets better without treatment, some children can get complications if they are not treated. Children get better faster when treated with an antibiotic. Your doctor will decide if an antibiotic is needed.

What can parents do?

If you think your child might have strep throat, see your doctor.

If your child has strep throat:

  • Washing your hands and your child’s hands is the best thing that you can do to stop the spread of germs.
  • Teach your child to cover his mouth with a tissue or with his sleeve or elbow when coughing or sneezing.
  • If your child has fever, give acetaminophen or ibuprofen.
    • Ibuprofen should only be given if your child is drinking reasonably well.
    • Do not give ibuprofen to babies under 6 months without first talking to your doctor.
    • Do not alternate between using acetaminophen and ibuprofen as this can lead to dosing errors.
    • A child or teenager with a fever should not be given aspirin .
  • Make sure your child gets plenty of rest and fluids.
  • Gargling with warm salt water can help soothe a sore throat.
  • Keep your child home from child care or school until she has taken the antibiotic for at least one full day.
  • Your child should take all the medication prescribed by the doctor, even if the signs of illness have gone away.

More information from the CPS:

  • Antibiotic use in infections

Reviewed by the following CPS committees:

  • Public Education Advisory Committee

Last Updated: July 2018

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