Recurring strep in child

Why your kid’s strep throat keeps coming back

Their findings, published in the Feb. 6, 2019, issue of Science Translational Medicine, suggest that recurrent tonsillitis is a multifactorial disease where immunological factors combined with an underlying genetic susceptibility allow group A strep to invade the throats of certain individuals time and again. Gaining a better understanding of why some children fail to develop protective immunity also opens the door to developing a vaccine to protect against strep throat, the researchers predict.

“We have 100+ years of experience with this disease but there really wasn’t any good explanation why some kids suffer from recurrent strep throat,” says the study’s senior author Shane Crotty, Ph.D., a professor in the Division of Vaccine Discovery. “We think that this is the first solid evidence that there is an important immunological component as well as a genetic one which together contribute to recurrent strep throat. Let’s try and build on it.”

“Repeated strep throat is the second most common indication for the removal of tonsils in children. Like every surgery it carries certain risks but there is recent data suggesting that tonsillectomy may increase the risk of upper respiratory tract diseases in the long term,” says pediatric otolaryngologist and senior co-author Matthew Brigger, M.D., M.P.H. , chief of the Division of Otolaryngology at Rady’s Children’s Hospital-San Diego. “My hope is that as we learn more about the causes behind recurrent strep infections we’ll be able to intervene before they happen.”

Strep throat is one of a diverse array of conditions caused by the bacterium Streptococcus pyogenes, better known as group A Streptococcus (GAS). It can cause pneumonia, scarlet fever, impetigo, which results in highly infectious skin sores, and necrotizing fasciitis, the feared flesh-eating disease. Unlike necrotizing fasciitis, strep throat is easily treated with antibiotics. But if left undiagnosed, it, too, can lead to serious complications.

“Here in the US we rarely see the consequences of untreated GAS infections,” says infectious disease physician and first author Jennifer Dan, M.D., Ph.D. Dan holds an appointment as Clinical Associate at LJI, which allows her to split her time between seeing patients at UC San Diego and doing advanced research in the Crotty laboratory. “But recurrent strep throat is a big concern in the developing world because kids who do not get antibiotics have a real risk of developing acute rheumatic fever or rheumatic heart disease, which is a major cause of acquired heart disease among young adults in the world.”

Trying to understand the longstanding mystery why some children are predisposed to frequent bouts of GAS tonsillitis and what their immune response looks like, the researchers turned to the tonsils themselves. Tonsils are lymph-node like structures located on each side of the back of the throat. Small pockets, or crypts, on their surface collect and sample microbes and can become the breeding ground for GAS.

Dan collected tonsil tissues from a cohort of children aged 5 — 18 who had their tonsils removed either because they suffered from repeated bouts of strep throat or underwent tonsillectomies for unrelated reasons such as sleep apnea. She was particularly interested in germinal centers, the central hubs where B cells have to team up with so-called follicular helper T cells (Tfh cells) to start producing antibodies.

In addition to a significant decrease in the frequency of both B and follicular helper T cells, tonsils from children with recurrent tonsillitis had consistently smaller germinal centers areas overall. “These kids have a poor germinal center response,” says Dan. “Interestingly it is associated with a particularly poor antibody response to SpeA, which is an important aspect of protective immunity.”

Short for streptococcal pyrogenic exotoxin, SpeA is not an essential component of the GAS genome. However, a particularly potent version of the toxin arose in the bacteria in the 1980s and these strains quickly swept the globe to become the most prevalent cause of strep throat. Children in the control group had high anti-SpeA antibody titers, which indicated that they had been exposed to the bacteria but did not get sick.

Among children with recurrent GAS tonsillitis the disease was likely to run in the family, suggesting a genetic component. Genetic testing revealed two specific genetic variants in the HLA region, which determines how pathogens interact with the immune system, that were associated with increased susceptibility to recurrent tonsillitis and one that protected against the disease.

“Since the immunological connection as well as the genetic connection are all tied to an insufficient antibody response against SpeA it suggests that recognizing this factor is actually a key problem for these kids,” says Crotty. “Having a vaccine that trains the immune system in advance might be able stimulate a protective immune response that can prevent recurring bouts of tonsillitis.”

When is it really recurrent strep throat?

Although that involves some detective work and perhaps some legwork by the provider or the office staff, it’s worth the effort, especially in an era of increased concerns about antimicrobial stewardship, said Dr. Bradley during an antimicrobial update session at the annual meeting of the American Academy of Pediatrics.

“Are the episodes really documented by you in your office?” asked Dr. Bradley. If so, the job is easier. If not, it’s important to differentiate whether documentation of the strep infection was done by culture, whether it was done by an extremely sensitive rapid test, or whether any testing has been done at all, said Dr. Bradley, chief of the division of infectious diseases at the University of California, San Diego.

Somehow, said Dr. Bradley, it’s still true that all group A streptococci are susceptible to penicillin, but penicillin does not always work. There’s about a 10% failure rate for reasons that are not completely understood. Perhaps some individuals have other oropharyngeal flora that produce beta-lactamases, thereby negating penicillin’s efficacy against the strep, he added.

One very good clue as to whether the child has recurrent strep is the appearance of the throat, said Dr. Bradley. A viral illness also can produce a very red posterior oropharynx, so – unless there’s frank pus – it’s unlikely to be strep pharyngitis.

Some patients will, in fact, have recurrent strep, but some patients who might even have positive rapid strep tests may actually be carriers.

So, “what the heck is the carrier state?” asked Dr. Bradley. Although a rapid strep test will occasionally be positive, he explained, the culture is only weakly positive, with growth that’s usually less than 1+. The child who’s a carrier is not symptomatic, will not have an elevated antistreptolysin O titer, and is not contagious. Also, the child will not respond to penicillin treatment.

How can clinicians differentiate recurrent strep from a child with frequent viral illnesses who’s a carrier?

“For the standard case of ‘recurrent strep,’ please get cultures and document the density of group A strep to rule out the carrier state,” said Dr. Bradley. Having parents text pictures of the throat during an episode – for which his facility has a secure portal – can save families an office visit. A negative antistreptolysin O titer can help rule out a recurrent infection, he added.

When a child is having recurrent bouts of pharyngitis, but the clinical picture isn’t clearly consistent with strep, physicians can consider submitting multiplex viral polymerase chain reaction tests. “This can give the family an alternative diagnosis” and reassure parents that it’s safe to hold off on antibiotics, noted Dr. Bradley.

Culturing between episodes of pharyngitis, when the patient is asymptomatic, can also help determine whether a child is a carrier. Sometimes, it makes sense to culture the whole family, and there have also been reports of family pets being Group A strep reservoirs, said Dr. Bradley.

For recurrent infection, choose a broad spectrum agent that will knock back both Group A strep and the oral flora that may be producing beta-lactamases or adhesion molecules that negate penicillin’s efficacy. One logical choice is clindamycin for 10 days, although some strains are resistant. Another good choice is amoxicillin/clavulanate for 10 days or 10 days of a cephalosporin. Penicillin can still be used if it’s augmented by oral rifampin during the last 4 days of the 10-day course.

Long-term prophylaxis can also be considered for stubborn recurrences, he noted.

Dr. Bradley reported no relevant conflicts of interest.

[email protected]

Why Do Some Children Suffer Strep Throat Over and Over Again?

Dr. Dan and colleagues found that children whose tonsils were removed due to recurrent infection had smaller germinal centers in their tonsils. Germinal centers live inside lymph nodes and help produce antibodies, the special proteins that fight off infection. Antibodies recognize and disable bacteria, and normally should be able to snuff out a strep infection before it strikes again.

“If these germinal centers are smaller, they might not be able to mount as good of an immune response,” Dan says.

The kids with recurrent tonsillitis were also more likely to have family members who had tonsillectomies, which suggests a genetic predisposition to a poor immune response.

Knowing exactly what causes recurring strep is also one of the keys to developing a vaccine. Matthew Brigger, MD, MPH, a study coauthor and the chief of otolaryngology at Rady Children’s Hospital in San Diego, says that not only would a vaccine address strep and other infections like tonsillitis, it would also reduce the need for surgeries like tonsillectomies.

“The surgery is very common and many children go through it, but it typically involves missing a week of school, there’s a risk of bleeding, and it’s one of the most painful surgeries we perform,” he says. “We do this surgery all the time, but we still don’t have a particularly good understanding of why some kids get it and others don’t.”

This month, the American Academy of Otolaryngology updated its guidelines for performing tonsillectomies in children — something that hadn’t been done since 2011. Tonsillectomies used to be an extremely popular procedure, with more than 500,000 children under age 15 undergoing tonsillectomy in 2009. That number has dropped by about half, with the most recent National Health Statistics Report showing fewer than 300,000.

Mary Frances Musso, DO, a pediatric otolaryngologist at Texas Children’s Hospital, says the two main reasons children have tonsillectomies are for sleep apnea and recurring infections. With the updated guidelines, Musso can still recommend the surgery, but only if the child has at least seven infections in one year. And even with the surgery, some children will continue to get strep.

A vaccine may be a ways off, but Dr. Musso says the recent study offers new evidence for the causes of recurring strep, which would be a critical first step in developing a vaccine.

“This is the first time I’ve actually heard of someone mentioning the possibility of finding a Group A strep vaccine,” she says. “What they’re saying potentially could work. If they can develop a vaccine, it may be efficacious and lower the infection rate.”

Strep Throat Over and Over: How Frequent? How Real?

Acute pharyngitis is one of the most common illnesses for which children visit pediatricians and other primary care physicians.1x1Armstrong, GL and Pinner, RW. Outpatient visits for infectious diseases in the United States, 1980 through 1996. Arch Intern Med. 1999; 159: 2531–2536
Crossref | PubMed | Scopus (66) | Google ScholarSee all References, 2x2Nash, DR, Harman, J, Wald, ER, and Kelleher, KJ. Antibiotic prescribing by primary care physicians for children with upper respiratory tract infections. Arch Pediatr Adolesc Med. 2002; 156: 1114–1119
Crossref | PubMed | Scopus (140) | Google ScholarSee all References Between 15% and 30% of pharyngitis episodes are reported to be associated with group A streptococcus (GAS)3x3Kaplan, EL, Top, FH Jr, Dudding, BA, and Wannamaker, LW. Diagnosis of streptococcal pharyngitis: differentiation of active infection from the carrier state in the symptomatic child. J Infect Dis. 1971; 123: 490–501
Crossref | PubMed | Scopus (280) | Google ScholarSee all References; some of these patients experience repetitive symptomatic bouts of sore throat associated with positive test results for GAS. In this issue of Mayo Clinic Proceedings, St. Sauver et al4x4St. Sauver, JL, Weaver, AL, Orvidas, LJ, Jacobson, RM, and Jacobsen, SJ. Population-based prevalence of repeated group A β-hemolytic streptococcal pharyngitis episodes. Mayo Clin Proc. 2006; 81: 1172–1176
Abstract | Full Text | Full Text PDF | PubMed | Scopus (9) | Google ScholarSee all References used the database of the Rochester Epidemiology Project to estimate a population-based period prevalence of recurring GAS pharyngitis episodes for the years 1996 to 1998. Cases were defined as children between 4 and 15 years of age who experienced 3 or more episodes within a 1-year period. Episodes were defined as “evidence of a sore throat” accompanied by either a positive rapid antigen detection test result or a positive throat culture for GAS occurring at least 30 days after the most recent pharyngitis episode. The authors concluded that a relatively small proportion of children, approximately 1% overall and 2% between 4 and 6 years of age, experienced repeated GAS-related episodes of pharyngitis during the time interval reviewed.

Even those low rates, however, may well be an overestimation. The methodology used, based solely on retrospective reviews of medical records and laboratory reports, has considerable limitations. The definition of an “episode” appears to be largely independent of clinical manifestations, which we believe were incompletely and therefore inadequately documented in the analyzed database. For example, in a random sample of 210 such episodes, the symptom of “sore throat” was recorded to be present in only 60% of patients. Similarly, other clinical findings often associated with streptococcal upper respiratory tract infection, such as pharyngeal erythema and tonsillar exudate, were documented as present in only approximately one third of cases. Temperature greater than 38°C was absent in two thirds of the 152 episodes for which temperature was recorded. Thus, one cannot be certain that many of these episodes would actually meet the accepted clinical profile (sudden onset, severe pain on swallowing, tonsillopharyngeal erythema, fever) usually associated with true acute GAS infection of the throat.5x5Bisno, AL, Gerber, MA, Gwaltney, JM Jr, Kaplan, EL, and Schwartz, RH. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis. 2002; 35: 113–125
Crossref | PubMed | Scopus (571) | Google ScholarSee all References, 6x6American Academy of Pediatrics. Group A streptococcal infections. in: LK Pickering (Ed.) Red Book: 2003 Report of the Committee on Infectious Diseases. American Academy of Pediatrics, Elk Grove Village, Ill; 2003: 573–584
Google ScholarSee all References, 7x7Wannamaker, LW. Perplexity and precision in the diagnosis of streptococcal pharyngitis. Am J Dis Child. 1972; 124: 352–358
PubMed | Google ScholarSee all References

A major issue that St. Sauver et al faced while performing these analyses was that of differentiating true GAS infection from episodes of chronic pharyngeal streptococcal carriage in patients with intercurrent viral infections. In prospective studies, this issue can be at least partially resolved by a number of methods, including serotyping/genotyping of recovered GAS isolates and determining the immune response to GAS extracellular antigens such as streptolysin O and streptococcal DNase B. Obviously, none of this information was available to the authors from their review of the medical records. They attempted to address this issue by identifying those episodes in which the signs and symptoms were more suggestive of viral rather than streptococcal infection, and such was the case in 21% of the reviewed records. The true figure may well be greater. For example, in one prospective study conducted a number of years ago, also in Minnesota, 57% of children with acute pharyngitis and positive GAS throat cultures failed to exhibit a diagnostic increase in antistreptolysin O or anti-DNase B,3x3Kaplan, EL, Top, FH Jr, Dudding, BA, and Wannamaker, LW. Diagnosis of streptococcal pharyngitis: differentiation of active infection from the carrier state in the symptomatic child. J Infect Dis. 1971; 123: 490–501
Crossref | PubMed | Scopus (280) | Google ScholarSee all References suggesting that they might have been carriers rather than children experiencing acute streptococcal infection.

While not completely solvable at the clinic level, one caveat from the American Academy of Pediatrics Redbook is worth remembering: “children with manifestations highly suggestive of viral infection, such as coryza, conjunctivitis, hoarseness, cough, anterior stomatitis, discrete ulcerative lesions, or diarrhea are unlikely to have GAS as the cause of their pharyngitis and generally should not be tested for GAS.”6x6American Academy of Pediatrics. Group A streptococcal infections. in: LK Pickering (Ed.) Red Book: 2003 Report of the Committee on Infectious Diseases. American Academy of Pediatrics, Elk Grove Village, Ill; 2003: 573–584
Google ScholarSee all References A high proportion of children with positive cultures or rapid antigen detection test results in such instances are likely to be streptococcal carriers.8x8Kaplan, EL. The group A streptococcal upper respiratory tract carrier state: an enigma. J Pediatr. 1980; 97: 337–345
Abstract | Full Text PDF | PubMed | Scopus (165) | Google ScholarSee all References Indeed, pharyngeal carriage rates of GAS in healthy children in schools and child-care centers may at times be 15% or even higher,6x6American Academy of Pediatrics. Group A streptococcal infections. in: LK Pickering (Ed.) Red Book: 2003 Report of the Committee on Infectious Diseases. American Academy of Pediatrics, Elk Grove Village, Ill; 2003: 573–584
Google ScholarSee all References and carriage of a single GAS strain may persist for many months.9x9Kaplan EL, Kurlan R, Van Gheem A, Johnson DR. Two year persistence of group A streptococci (GAS) in the throat accompanied by falling streptococcal antibody titers: the upper respiratory tract carrier state confirmed and microbiologically/immunologically examined . Presented at the Pediatric Academic Societies’ Annual Meeting; San Francisco, Calif; April 29-May 2, 2006.
Google ScholarSee all References Determining the presence or absence of GAS in the pharynx during asymptomatic intervals may be helpful to some extent in differentiating chronic carriage from acute streptococcal pharyngitis. We suspect that many of the children in the Rochester study with frequent recurrences (≥7 in 38 patients) may well have been in this category. In addition to chronic carriage, other possible explanations are noncompliance with the prescribed antimicrobial regimen; a new infection acquired from family, classroom, or community contacts; or true treatment failure, ie, a second episode of pharyngitis caused by the original infecting strain. However, the last-mentioned occurs rarely.

Regardless of the exactitude of the period-prevalence estimate, we concur with the authors that the absolute number of children they found to be visiting primary care physicians repeatedly with GAS-positive sore throats is substantial at the population level. This represents not merely a conundrum for the epidemiologist but a management problem for the practitioner. Although not the focus of the article by St. Sauver et al, it is worth noting that suggestions to clinicians for dealing with such perplexing patients are spelled out in the Practice Guidelines of the Infectious Disease Society of America.5x5Bisno, AL, Gerber, MA, Gwaltney, JM Jr, Kaplan, EL, and Schwartz, RH. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis. 2002; 35: 113–125
Crossref | PubMed | Scopus (571) | Google ScholarSee all References Those guidelines also provide specific antibiotic regimens most likely to terminate carriage, in the event that this strategy (not routinely recommended) is required to help clarify the situation. The role of tonsillectomy is often discussed for children with frequent recurrent sore throats. This procedure may decrease the number of recurrences in some patients, but only for a limited time,10x10Paradise, JL, Bluestone, CD, Bachman, RZ et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children: results of parallel randomized and nonrandomized clinical trials. N Engl J Med. 1984; 310: 674–683
Crossref | PubMed | Scopus (371) | Google ScholarSee all References and it is recommended only in the most severe cases.11x11Paradise, JL, Bluestone, CD, Colborn, DK, Bernard, BS, Rockette, HE, and Kurs-Lasky, M. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics. 2002; 110: 7–15
Crossref | PubMed | Scopus (171) | Google ScholarSee all References

The authors advocate further studies “to determine how best to reduce episodes and treatment costs in this group of children.” Although it is hard to question this laudable goal, we wonder whether the low overall period prevalence reported from this retrospective database in the defined population of Rochester and Olmsted County, Minnesota, justifies the effort and expense of such studies. Given the ubiquity of GAS, is a 1% period-prevalence rate of recurrent episodes near the irreducible minimum? Such efforts could be justifiable, however, in other populations with high rates of occurrence of nonsuppurative streptococcal sequelae or of invasive streptococcal diseases.

Substantial current research is directed toward the development of a safe and effective vaccine to prevent GAS infections and their life-threatening suppurative and nonsuppurative sequelae.12x12Bisno, AL, Rubin, FA, Cleary, PP, and Dale, JB. Prospects for a group A streptococcal vaccine: rationale, feasibility, and obstacles—report of a National Institute of Allergy and Infectious Diseases workshop. Clin Infect Dis. 2005; 41: 1150–1156 (Epub 2005 Sep 2.)
Crossref | PubMed | Scopus (77) | Google ScholarSee all References There are a number of vaccine candidates, some of which have already been subjected to limited testing of safety and immunogenicity in human volunteers. Should these efforts be successful, this group of children with repetitive symptomatic cases of acute GAS-positive pharyngitis might well be among the most grateful of recipients, and such gratitude would surely be shared by their parents and physicians.

Strep throat is common in kids, but many parents have misconceptions

As children from all over Middle Tennessee begin to settle back into a school routine this time of year, parents all over Middle Tennessee begin to worry about their children catching something and getting sick from being in close quarters with large numbers of other kids.

One bacterial infection that is very prevalent among school-aged children this time of year and into the winter is strep throat. It’s something most every parent has heard of and quite possibly dealt with multiple times. But how many parents actually understand what it is and how it’s treated?

We spoke with pediatrician Alexander Brunner, M.D., from Mercy Community Healthcare and Williamson Medical Center epidemiologist Shaefer Spires, M.D., about strep and the very common misconceptions surrounding it.

MYTH #1 – Any sore throat is probably strep.

Because strep has become synonymous with soreness of the throat, it tends to be the blanket term for any type of soreness in that area. But there are other symptoms that can rule out strep throat as a cause for the discomfort.

“Strep throat is technically an infection of your throat that is caused by Streptococcus pyogenes bacteria,” Spires says. “But the biggest thing to note is that 80 percent of the time, a sore throat is caused by a virus. If you or your child have a sore throat, it’s up to your provider to determine whether it is caused by a virus or bacteria.”

Spires adds that some symptoms not commonly associated with strep are conjunctivitis (or pink eye), cough, runny nose, or ulcers in the mouth.

Brunner says one of the key things doctors look at when diagnosing strep is the absence of a cough.

“Indicators of strep are a fever, swollen tonsils and lymph nodes in the neck and not having a cough,” Brunner says. “If you have all four of those, more than likely, it’s strep.”

MYTH #2 – The rapid in-office strep test is always accurate.

There are two ways to test to see if a person does indeed have strep. There is a rapid test done in the physician’s office that takes just a few minutes. The results, however, are not always accurate.

“The gold standard in diagnosing strep is a throat culture,” Brunner says. “But the problem is because the culture has to be sent off and watched for a few days, we don’t see results for 48-72 hours.”

Spires added that the rapid test isn’t as sensitive as a culture, so it can miss positive cases of strep.

“That’s why, in most cases, if a rapid test is negative, the provider will automatically send for a culture which has a much higher sensitivity,” he says. “With that culture, we are literally waiting for the bacteria to grow in a lab. That can take up to three days.”

MYTH #3 – Strep is spread only by touching surfaces contaminated with the bacteria.

That is one way a person can get strep, but according to Spires, it spreads just like a virus does — via droplets. Someone coughs or sneezes and you can actually breathe in those droplets and catch strep.

“Those droplets can land on the doorknob or the counter. You get that on your hand and touch your nose or mouth and you will very likely get it,” Spires says. “Strep is as contagious as any virus, if not more. It’s rare as far as bacteria goes in that it can be spread by droplets and live on inanimate surfaces for a period of time.”

Brunner adds that strep is definitely more common when children are congregating and the weather keeps people inside.

“Strep tends to be more prevalent in the pediatric population,” Brunner says. “That is because kids are more apt to put dirty hands in their mouths and they also have larger tonsils, which could contribute to it as well.”

The best way to prevent strep from spreading is for parents to encourage good hand hygiene with their children.

“Make sure they wash their hands before they eat and use hand sanitizer,” Brunner says. “We also discourage kids from sharing juice or drinks with their classmates. Also, after a child has strep, we recommend a child changing their toothbrush and to not share toothpaste with siblings. Parents need to be cognizant that this spreads by contact with the mouth, so it’s important to be very aware of that.”

MYTH #4 – Antibiotics can help any sore throat.

This may be among the biggest misconceptions in the pediatric community that causes a struggle for pediatricians who have to explain to parents that antibiotics are not always the amazing cure-all. In fact, too many antibiotics can have a negative impact on a child’s health.

“If a child has a sore throat that is caused by a virus, receiving antibiotics does absolutely nothing,” Spires says. “If you ask for antibiotics when they aren’t warranted, you are exposing your child to the effects of an antibiotic, including GI upset, allergic reactions, another infection called C Diff, and you are contributing to the development of multi-drug-resistant bacteria.”

Brunner adds, “We don’t want to treat for strep if it’s not strep that’s causing these other infections.”

Spires concurs, saying the prevention of unnecessary antibiotic use begins with the provider before a test is even administered.

“If a child has a runny nose and a sore throat, most likely that is a viral infection, so a strep test isn’t even necessary,” says Spires. “This eliminates a false positive test and unnecessary antibiotics.”

MYTH #5 – You can get recurrent episodes of strep.

“You don’t get recurrent strep,” Spires says. “You get recurrent viral infections.”

Spires says he hears even in his own family that someone’s child has gotten strep four times back-to-back, which isn’t the case.

“Strep is easily killed by penicillin, so it doesn’t come back right away. It works 100 percent of the time in treating group A strep,” he says. “There could be a scenario where a child keeps getting a cold or upper respiratory infection — which includes a cough, runny nose and sore throat — and they keep testing positive for strep. This is someone who is an asymptomatic carrier of strep.”

Brunner’s job is explaining that to a parent.

“Basically, a parent may say that their kid gets strep all the time, which can mean they are just a carrier,” Brunner says. “What we try to do is tell the parents that strep is bacteria that can sometimes live in the back of the throat and not cause an infection. If a child has a fever and runny nose, they could have strep in the throat that will make a test positive, but that’s not what’s causing their symptoms and we don’t want to treat for strep if it’s not strep that’s causing these other infections.”

Brunner says if a child has had six episodes with strep in one year, that’s when a pediatrician will recommend having their tonsils removed.

“If we can get them out, we can eliminate the carriage of the strep so it isn’t a chronic issue of treating strep when that’s not causing the problem.”

Alexander Brunner, M.D., is board certified in internal medicine and pediatrics and practices at Mercy Community Healthcare in Franklin. His office can be reached at 615-790-0567. S. Shaefer Spires, M.D., is board certified in infectious disease and is the hospital epidemiologist for Williamson Medical Center. For more information, visit www.williamsonmedicalcenter.org.

Parenting in the Early Years

Streptococcal Infections

Related Topics

Recognizing Signs of Illness

Many infections are caused by bacteria called Streptococci. The most well known are the infections caused by Group A strains, which include strep throat and a skin infection called impetigo. Not uncommonly, infants and toddlers can have strep infections in the nose, anus or vagina.

Strep throat is usually accompanied by throat pain, high fever, headaches and swollen neck glands. The throat becomes inflamed and there are often white spots on the tonsils, red spots on the soft palate and the tongue may become rough and bumpy. Stomachaches and vomiting are common. If a red, sandpaper type rash develops with strep throat it is then called Scarlatina or Scarlet Fever.

Unfortunately, strep infections can have some severe consequences. One complication of strep infection is Rheumatic Fever. This causes heart damage, arthritis and possible damage to the nervous system. Strep infections can also cause a kidney disease called glomerulonephritis.

There is a very aggressive type of strep that has been associated with pneumonia and blood infection, causing death in a short amount of time. Fortunately, this strain of strep is rare.

The diagnosis of strep throat is suspected by a history and physical exam. The diagnosis is confirmed by obtaining a swab of the throat and if indicated a rapid strep test is done. If the rapid test is negative a throat culture is done that takes one or two days for an answer.

Strep infections are treated with antibiotics, penicillin being the most frequently prescribed. If your child is allergic to penicillin another antibiotic will be prescribed. Response to treatment is quite fast and definite improvement should occur within 48 hours. Occasionally a strep infection will not respond to treatment and another antibiotic will be needed. If your child does not improve, contact your doctor. It is very important to take the full ten days of the medication as prescribed.

An infected child is contagious until he has been on medicine for 24 hours. It takes 5 to 14 days for the strep to grow in someone who has been exposed. If you culture the exposed person during that incubation stage you can recover the strep germ. Sometimes several members of a household become infected with strep and will need to be seen by their physician.

If a child develops recurrent strep infections, other household members will need to be checked to see if they are the source of strep.

Tonsillectomy may be indicated if your child has five documented strep throat infections in a year or three infections per year for two or more consecutive years.

Attempts should be made to keep your child comfortable and well hydrated. Ice cream and popsicles frequently provide temporary relief from throat pain while providing fluids. Acetaminophen or ibuprofen give fever and pain relief and are safe to give along with antibiotics.

For kids, getting strep throat again and again is a pain. It’s also a problem little understood by scientists. Now a study that analyzed kids’ tonsils hints at why such repeat infections may happen.

Children with recurrent strep infections had smaller immune structures crucial to the development of antibodies in their tonsils than kids who hadn’t had repeated infections, researchers found. The frequently sore-of-throat were also more susceptible to a protein, deployed by the bacteria that cause the infection, that disrupts the body’s immune response, the team reports online February 6 in Science Translational Medicine.

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Globally each year, there are an estimated 600 million cases of strep throat, which commonly produces a sore throat and fever. Doctors treat the illness with antibiotics, especially in children, who are at highest risk of developing rheumatic fever and heart problems from a strep infection. But some kids, even though they get treatment, repeatedly develop new cases of strep throat.

In the study, immunologist Shane Crotty of the La Jolla Institute for Immunology in California and colleagues examined tonsils, the immune tissue found at the back of the throat, that had been removed from 5- to 18-year-olds. Some of the children had their tonsils taken out because of recurrent strep infections. Others had their tonsils removed to resolve sleep apnea caused by enlarged tonsils; this group was a proxy for kids not plagued by repeated bouts of strep.

The team looked at sections of tissue under a microscope and found that kids with recurring strep had smaller immune structures called germinal centers, and the centers had fewer of a particular kind of immune cell, a type of T cell. Those T cells help other immune cells, known as B cells, make antibodies that help the body fight an infection.

The kids with recurring strep also had fewer antibodies to a protein, used by the bacteria called group A Streptococcus, that interferes with the immune response to the pathogen. That may make the children more susceptible to infections, Crotty says.

The research is elegant and intriguing, says pediatrician Stanford Shulman, who specializes in infectious disease at the Ann & Robert H. Lurie Children’s Hospital of Chicago and was not involved in the study.

But one caveat, he says, is that sometimes kids classified as having recurrent strep infections are actually carriers of group A Streptococcus, meaning the bacteria is latent in their tonsils but not causing symptoms. In those cases, a sore throat due to a viral infection would still come up as strep in a test. It’s estimated that roughly 20 percent of school-aged children are chronic carriers of group A Streptococcus.

It’s possible the seemingly defective immune response towards strep that the study reports could be due to some of those kids being carriers of the bacteria rather than having active strep infections, Shulman says. In future work, it would be helpful to determine which kids have true recurrent infections and which kids are strep carriers, he says.

For kids, getting strep throat over and over is a pain. It’s also a problem that has puzzled scientists. Now a study of kids’ tonsils suggests what’s up. Some kids have a faulty immune response to strep bacteria. Others are misdiagnosed with the disease when strep germs hide out in their tonsils.

That’s the finding of a study published online February 6 in Science Translational Medicine.

Each year, strep throat sickens some 600 million people across the globe. Bacteria called group-A Streptococcus are to blame. The sickness can cause a sore throat, fever and more. Kids who get the disease are at risk of heart problems and rheumatic fever (a non-infectious but very serious disease).

Doctors treat strep throat with antibiotics. Still, some treated kids keep getting strep throat again and again. These children and teens tend to have smaller immune structures in their tonsils than kids who hadn’t had repeated infections, a new study finds. Those immune structures help make antibodies — proteins that fight off bacteria and viruses.

Tonsils may be key

Shane Crotty studies the immune system at the La Jolla Institute for Immunology. It’s in Southern California. For a new study, he and his colleagues examined tonsils from kids 5- to 18-years old. Some had their tonsils taken out because of frequent strep throat. Others had theirs removed to fix breathing problems caused by big tonsils. This second group was a stand-in for kids who don’t get recurring strep throat.

The team looked at pieces of the tonsils under a microscope. Kids with recurring strep had smaller immune structures called germinal (GER-mih-nul) centers. And these centers made fewer immune cells known as T cells. T cells help other immune cells known as B cells make antibodies.

J.M. DAN ET AL/SCIENCE TRANSLATIONAL MEDICINE 2019 Kids with repeated bouts of strep throat had smaller immune structures (brown) in their tonsils (left in these microscope images) than kids who without repeat infections (right).

Infection-fighting antibodies come in many forms. Kids with recurring strep had fewer of these that respond to a protein in group A strep. That protein helps the microbe mess with the immune system. That protein may leave kids more prone to future infections, Crotty says.

The research is elegant and intriguing, says Stanford Shulman. He is a doctor that studies infectious disease in kids. Shulman works at the Ann & Robert H. Lurie’s Children’s Hospital of Chicago in Illinois. He was not involved in the research.

But sometimes, Shulman warns, kids diagnosed with recurrent strep throat aren’t sick. Because of some earlier infection, strep bacteria now live harmlessly in their tonsils. In such cases, a sore throat due to a virus might now be mistaken as strep throat. The reason? Tests can turn up signs that the body hosts the strep germ. An estimated 20 percent of school-aged kids are such chronic hosts of group A strep.

It’s possible some kids in the study’s recurrent strep-throat group were carriers, too, Shulman says. Future work, Shulman says, should determine which kids truly get repeat strep throat infections and which kids are strep carriers who might have been sickened this time by something else.

Intact Tonsils Triple Risk Of Recurrent Strep Throat

“These results suggest that tonsillectomy is a useful therapy for treating children with recurrent strep throat infections,” says Laura Orvidas, M.D., Mayo Clinic ear, nose and throat surgeon and senior study investigator. “It should decrease the amount of infections experienced by this subset of children and therefore diminish the number of missed school days and hopefully improve overall quality of life.”

Dr. Orvidas and colleagues conducted a population-based retrospective cohort study of children between ages 4 and 16 who received three or more diagnoses of strep-related tonsillitis or pharyngitis at least one month apart, within 12 months. Within this group, children who subsequently underwent a tonsillectomy were compared with an age- and sex-matched sample of children who had not had a tonsillectomy. The date of the tonsillectomy for the matched pair was defined as the index date. All strep infections were recorded for both groups of children.

The study population comprised 290 children (145 who received a tonsillectomy and 145 who did not). In the tonsillectomy group, 74 children experienced at least one strep infection after the index date and before age 16. Among those who did not receive a tonsillectomy, 122 experienced at least one strep infection during the follow-up. The time before first subsequent strep infection was much longer for those who had a tonsillectomy, a median of 1.1 years as compared to 0.6 years for children whose tonsils had not been removed. By one year after the index date, the cumulative incidence of a strep infection was 23.1 percent among the children who had a tonsillectomy compared to 58.5 percent among the children who had not.

Researchers used the Rochester Epidemiology Project to identify children for the study, which was limited to children who resided in Olmsted County, Minn., between Jan. 1, 1994, and Dec. 31, 1998. The Rochester Epidemiology Project has developed an index for the records of virtually all providers of medical care in Olmsted County. Olmsted County is served by a largely unified medical care system, including Mayo Clinic, that has accumulated comprehensive clinical records since the early 1900s.

“The use of the Rochester Epidemiology Project resource was unquestionably one of the strengths of the study,” says Dr. Orvidas. “This resource allowed us to access complete medical records on a geographically defined pediatric population and minimized potential referral and participation biases.”

The next step of the research phase, according to Dr. Orvidas, would be a prospective randomized trial investigating the use of tonsillectomy for recurrent strep throat infections. Such an investigation could judge outcomes based on the number of subsequent infections and on quality of life issues, she says.

Pharyngitis and tonsillitis are among the most commonly diagnosed pediatric illnesses, accounting for approximately 18 million physician office visits per year. Strep infections are responsible for 15 percent to 30 percent of all cases of pharyngitis. In addition, 20 percent to 30 percent of children who are diagnosed with strep pharyngeal infection may experience a second infection within 60 days of the initial episode.

Study authors also include Jennifer L. St. Sauver, M.D., and Amy L. Weaver.

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