Chapter 2 Index

A. Evaluation by system:

1. General

2. HEENT
--Otitis Media:
Classification, Rx and Complications
--Pediatric ENT:
1. When to Refer for Tubes
2. Laryngeal Abnormalities
--The Treatment of Otorrhea
--Eye Problems of Children
--Allergic Rhinitis
--Sinusitis vs. Purulent Rhinitis vs. URI
--“Treatment” of the Common Cold
--Frequently Used OTC Medications for the Common Cold
--Facial Nerve Palsy in Pediatrics

Strep Throat – Any Different in the Year 2002?

Introduction: Many of the issues concerning strep throat have not changed in decades.

Incubation period: 2-4 days but can be as long as 7 days; Contagious Period: 24 hrs after meds

Epidemiology: see mostly in October – May

Signs and Symptoms: Fever, sore throat, exudate, petechiae on the soft palate, edematous uvula, anterior cervical nodes, rash starting in axilla and groin and then spreading to the rest of the body, abdominal pain, headache, vomiting.

Rapid Streptococcal Antigen Tests:

1. Waived Tests: many different waived tests available.  We are using ICON Fx.
2. Moderately Complex Tests - No advantage over waived tests.  Sensitivity and specificity around 90-95% for both types of testing.

Culture:  All subgroups of streptococci will give beta hemolysis on sheep agar.  (Groups A through H and K through V have been identified)

• Must use bacitracin disc --- zone of inhibition means Group A strep. Group C is not inhibited by the bacitracin disc but can cause disease.
• Cultures now are graded 1+ to 4+ depending on number of colonies on the plate; 1+ is less than 10 colonies and probably is insignificant; 2+ between 10 and 20 colonies, etc.
• Recommendation (Redbook): all negative rapid strep tests be backed up with a culture.

Problems exist because:

• Experienced physicians do no better than others in diagnosing strep throat: 25% of exudative pharyngitis is strep; strep present in 15% of the cases of pharyngitis.
• Some managed care companies often do not allow testing in the office
• Why not just treat? 74% of children with pharyngitis will get treatment they do not need.
• 15% carriage state in all children – carriage state is not a pathological condition.

Common Clinical Problems Associated with Strep Pharyngitis:

1. How many infections necessitate doing a T and A in a school-aged child? More than 3 positive cultures in a child in a year, Alternative to surgery: use daily prophylaxis of penicillin.

2. If throat looks normal, and you get a 1+ Group A growth on the plate, should that child be treated with antibiotics?  What about 2+?  Most practitioners end up treating these children. Must remember that 15% of children carry strep at a time ---- different children at different times will carry strep and have no symptoms.  Carriage state can be eradicated with Clindamycin (20/k/d) or Bicillin with Rifampin bid x 4 days.  No reason usually to do this.

3. How do you treat strep throat - initial treatment? 

• Oral Penicillin, Amoxicillin (can be BID or one dose per day up to 750 mg/day),
• Cephalosporins, Biaxin, Erythro., Azithromycin, Rifampin plus penicillin x last four days

4. How do you treat recurrent strep?  Bicillin (Benzathine penicillin) is commonly used; if child having severe symptoms, use CR Bicillin (900,000 Benzathine, 300,000 Procaine Penicillin).

Reviewed 1/02

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Department of Pediatrics  |  Medical College of Georgia
Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004