Disease: Strep Throat

    Strep throat facts

    • Most sore throats are caused by viruses, not strep bacteria.
    • Symptoms of strep throat in middle-age children and adolescents include:
      • Sore throat (90%)
      • Headache (85%)
      • Fever (85%)
      • Upset stomach (65%)
    • Symptoms associated with an upper respiratory infection (a "cold") are typically absent (for example, nasal congestion, cough, muscle aches and pains, nasal congestion, and oral blisters).
    • The diagnosis of strep throat is established either via a rapid strep test (RADT) or a throat culture.
    • Strep throat is cured by appropriate antibiotic therapy.
    • While rare, there are several complications that may develop from a strep throat infection.

    What is strep throat and what causes strep throat?

    Strep throat is a bacterial infection of the soft palate and tonsillar region. Microbiologists identify the member of the Streptococcus bacterial family that causes strep throat as "GAS" (Group A, beta hemolytic, Streptococcus pyogenes). Strep throat is most common in young children and adolescents, but it is not unusual in toddlers and adults. It is highly contagious and it is present most commonly in the community during the winter months. Interestingly, the symptoms and physical signs may vary depending upon the age of the infected patient.

    What are the signs and symptoms of strep throat?

    Signs of strep throat are not unique - indeed many viral infections (which cause the large majority of sore throats) can have identical signs and symptoms as a GAS infection. Typically, an older child and adolescent will have several core symptoms such as:

    • Fever (generally 102 F [38.8 C] and higher)
    • Sore throat (may vary from mild to moderate in severity)
    • Headache
    • Upset stomach with nausea occasionally severe enough to cause mild vomiting

    Of note is that runny nose, cough, hoarse voice, muscle aches, diarrhea and oral blisters are generally not seen with a strep throat infection. These latter symptoms are more commonly indicative of a sore throat caused by a virus.

    Signs of strep throat infection include:

    • Redness of the soft palate, uvula (the "punching bag" structure hanging from the back of the soft palate) and tonsils. Commonly the tonsils may have a bumpy character to their surface - somewhat like a golfball.
    • A purulent discharge on the tonsils (exudate)
    • Petechiae (1-2 mm bright red "dots" which represent ruptured capillaries) scattered on the soft palate. The presence of these "white spots" is often associated with bad breath (halitosis).
    • Enlarged and tender neck lymph nodes (also known as lymph glands), and occasionally
    • A diffuse rash over the torso and groin region. The classic description of this rash is that of "goose bumps on a moderate sunburn."

    The presence of a strep infection and this specific rash is termed scarlet fever. Such a diagnosis does not imply a more severe GAS infection or imply any change in prognosis or management. The rash is not contagious. It is important to note that while most patients with strep throat will experience these signs and symptoms, not all will necessarily be present in each individual.

    Are the signs and symptoms of strep throat different in various age groups?

    The information listed above is seen in those most likely to have a strep throat infection - individuals that are older children and teenagers. However, other age groups may experience a different constellation of findings with a strep throat infection.

    • Infants: more commonly have a thick purulent nasal discharge, low grade fever (< 101 F [38.33 C]), reduction in appetite and fussiness.
    • Toddlers: children from one to three years of age may complain of a sore throat, have pain with swallowing and subsequently a limited appetite, and swollen lymph nodes (lymph glands) beneath the mandible (lower jaw bone).
    • Adults: strep throat may have milder symptoms and thus may not prompt a medical evaluation unless an exposure history to strep throat is known.

    Is strep throat contagious?

    Strep throat is moderately contagious and is most commonly spread via direct person-to-person contact. Passage of airborne droplets and/or saliva from the infected individual to another is the most likely mechanism of contracting strep throat. As such, close living quarters (home, classroom, day care centers, college dorms, etc.) provide an ideal environment for passage of GAS bacteria from one person to another. The risk of contracting a strep throat infection is approximately 40% in household environments. Most infectious disease specialists believe that a patient is no longer contagious after 24 hours of effective antibiotic therapy. Spread of strep bacteria via food borne transmission is less common than direct person-to-person exchange of droplets or saliva. The exact likelihood of developing strep throat from family pets is unknown, but most experts believe it is minimal.

    How is strep throat diagnosed?

    There are two common tests used to establish whether an individual with symptoms of strep throat infection has a strep throat. The traditional test, a throat culture, involves the doctor obtaining a swab from the back of the throat and tonsils. It takes approximately 36 to 48 hours to determine the presence or absence of the GAS bacteria. This test is considered the "gold standard" in diagnosing strep throat.

    Many medical offices, clinics and hospital emergency departments use a rapid strep test (RADT - rapid antigen detection test) in an effort to provide a more timely diagnosis for their patients. The throat swab is obtained similarly to that for a traditional throat culture, but a RADT "kit" is employed to help determine the presence or absence of the strep bacteria. The turn around time is generally 10 minutes. The RADT is less precise when compared with a throat culture. Most RADT tests are about 95% accurate in determining the presence of strep bacteria. Most guidelines recommend that a negative rapid strep test be confirmed with a throat culture. Of note, antibiotic pretreatment prior to obtaining a throat swab for strep bacteria can interfere with throat culture results, and thus the ability to correctly diagnose and treat a strep throat infection. Antibiotic treatment prior to a rapid strep test is less likely to have a false negative result since the test is designed to document the presence or absence of the GAS bacteria. Residual dead bacteria in the patient may allow a positive result.

    The above tests are designed to determine whether an individual currently has a strep throat infection. Sometimes it may be necessary to determine whether a patient has had a recent history of a strep infection. In that case, two blood tests are available: (a) an ASO (anti streptolysin O) titer, and/or (b) an anti DNase titer. The antibodies that these tests are sensitive to are not commonly present until a few weeks following an acute strep infection. These tests may be ordered when evaluating a patient who may have developed delayed complications (such as rheumatic fever or glomerulonephritis) after a strep throat infection.

    What is the treatment for strep throat?

    Treatment of a strep throat infection includes the use of antibiotics and over-the-counter medications and home remedies for the reduction of symptoms.

    What are home remedies for strep throat?

    There are a number of home remedies that may be used for symptom reduction. They may be used whether the patient has strep throat or a viral cause of their illness. These remedies should not be used in lieu of a complete course of antibiotics if a GAS infection is being treated. Home therapies include:

    • Saltwater gargle: mix ¼ to ½ teaspoon with 8 ounces of warm water. Young children may swallow the solution instead of gargling it and should thus avoid this approach.
    • Hard candies or throat lozenges may be sucked on for effective reduction of symptoms.
    • Ice cream, smoothies, popsicles, cold drinks, and warm tea with honey may be useful to soothe the sore throat. Honey should be avoided in infants less that 1 year of age because of their increased likelihood of botulinum toxicity and paralysis.

    What over-the-counter) OTC drugs are helpful reducing strep throat symptoms?

    Several over-the-counter (OTC) medications, such as acetaminophen (Tylenol) and ibuprofen (Advil and Motrin), can be used to lower the fever and provide pain relief for the sore throat. Aspirin should not be used in children or adolescents because of its association with Reye's syndrome.

    What antibiotics are prescribed to treat strep throat?

    • Antibiotics provide the mainstay for successfully treating a strep throat infection.
    • The GAS bacteria are generally susceptible to the penicillin family (for example, amoxicillin [Amoxil]) and the cephalosporin family (for example, cephalexin [Keflex], cefprozil [Cefzil), cefdinir [Omnicef] and others).
    • Members of the macrolide family (for example, erythromycin [E-mycin], azithromycin [Zithromax] and clarithromycin [Biaxin]) are generally felt to be less effective than the other two classes of antibiotics, but are used in individuals with moderate penicillin or cephalosporin allergy. If such a patient cannot tolerate the macrolide family, clindamycin (Cleocin) is an alternative and very effective antibiotic option.
    • Regardless of what antibiotic is prescribed, it is incumbent to complete the entire course of the antibiotic. A rapid reduction in symptoms within 24 to 48 hours is to be expected. Viral throat infections do not require antibiotics since they provide no benefit.

    What are the potential complications of strep throat?

    The possible complications of strep throat include:

    • Acute rheumatic fever (see below),
    • Glomerulonephritis (see below),
    • Otitis media (middle ear infection),
    • Toxic shock syndrome (a rare but severe complication which may result in the failure of multiple organs and may thus be fatal),
    • Peritonsillar abscess or retropharyngeal abscess (walled off infection containing GAS bacteria and pus which may encroach upon the structures in the back of the throat or invade and rupture into deeper structures which may ultimately be fatal), and PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep) - (see below).

    Acute rheumatic fever (ARF): While rare, this complication of an untreated or inadequately treated strep infection can have devastating and lifelong consequences. It is believed that due to incomplete eradication of the strep bacteria, certain GAS cause an immune response which may attack the joints leading to permanent arthritis. More concerning is the autoimmune response to the heart valves which may damage them and may result in heart failure. Many studies have shown that effective and appropriate antibiotic therapy for strep throat vastly reduces the likelihood of developing ARF.

    Glomerulonephritis: Similar to the aberration of the immune response seen with ARF, autoantibodies may develop to the microscopic filters (glomeruli) of the kidney. This complication more commonly affects children between 7 to 10 years of age. While more common than acute rheumatic fever, glomerulonephritis carries a less ominous prognosis. Helpful therapies exist and most children make a complete recovery and do not experience long-term kidney damage. Unlike ARF, the development of glomerulonephritis is not necessarily prevented by effective antibiotic treatment.

    PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep): Specialists debate the proposed link of a GAS infection in children with the development and/or worsening of obsessive-compulsive behaviors or tic disorder (Tourette's syndrome in the extreme). One area being researched in this controversial condition is whether antibiotic therapy affects the development of or severity of the disorder.

    What are the signs and symptoms of strep throat?

    Signs of strep throat are not unique - indeed many viral infections (which cause the large majority of sore throats) can have identical signs and symptoms as a GAS infection. Typically, an older child and adolescent will have several core symptoms such as:

    • Fever (generally 102 F [38.8 C] and higher)
    • Sore throat (may vary from mild to moderate in severity)
    • Headache
    • Upset stomach with nausea occasionally severe enough to cause mild vomiting

    Of note is that runny nose, cough, hoarse voice, muscle aches, diarrhea and oral blisters are generally not seen with a strep throat infection. These latter symptoms are more commonly indicative of a sore throat caused by a virus.

    Signs of strep throat infection include:

    • Redness of the soft palate, uvula (the "punching bag" structure hanging from the back of the soft palate) and tonsils. Commonly the tonsils may have a bumpy character to their surface - somewhat like a golfball.
    • A purulent discharge on the tonsils (exudate)
    • Petechiae (1-2 mm bright red "dots" which represent ruptured capillaries) scattered on the soft palate. The presence of these "white spots" is often associated with bad breath (halitosis).
    • Enlarged and tender neck lymph nodes (also known as lymph glands), and occasionally
    • A diffuse rash over the torso and groin region. The classic description of this rash is that of "goose bumps on a moderate sunburn."

    The presence of a strep infection and this specific rash is termed scarlet fever. Such a diagnosis does not imply a more severe GAS infection or imply any change in prognosis or management. The rash is not contagious. It is important to note that while most patients with strep throat will experience these signs and symptoms, not all will necessarily be present in each individual.

    Are the signs and symptoms of strep throat different in various age groups?

    The information listed above is seen in those most likely to have a strep throat infection - individuals that are older children and teenagers. However, other age groups may experience a different constellation of findings with a strep throat infection.

    • Infants: more commonly have a thick purulent nasal discharge, low grade fever (< 101 F [38.33 C]), reduction in appetite and fussiness.
    • Toddlers: children from one to three years of age may complain of a sore throat, have pain with swallowing and subsequently a limited appetite, and swollen lymph nodes (lymph glands) beneath the mandible (lower jaw bone).
    • Adults: strep throat may have milder symptoms and thus may not prompt a medical evaluation unless an exposure history to strep throat is known.

    Is strep throat contagious?

    Strep throat is moderately contagious and is most commonly spread via direct person-to-person contact. Passage of airborne droplets and/or saliva from the infected individual to another is the most likely mechanism of contracting strep throat. As such, close living quarters (home, classroom, day care centers, college dorms, etc.) provide an ideal environment for passage of GAS bacteria from one person to another. The risk of contracting a strep throat infection is approximately 40% in household environments. Most infectious disease specialists believe that a patient is no longer contagious after 24 hours of effective antibiotic therapy. Spread of strep bacteria via food borne transmission is less common than direct person-to-person exchange of droplets or saliva. The exact likelihood of developing strep throat from family pets is unknown, but most experts believe it is minimal.

    How is strep throat diagnosed?

    There are two common tests used to establish whether an individual with symptoms of strep throat infection has a strep throat. The traditional test, a throat culture, involves the doctor obtaining a swab from the back of the throat and tonsils. It takes approximately 36 to 48 hours to determine the presence or absence of the GAS bacteria. This test is considered the "gold standard" in diagnosing strep throat.

    Many medical offices, clinics and hospital emergency departments use a rapid strep test (RADT - rapid antigen detection test) in an effort to provide a more timely diagnosis for their patients. The throat swab is obtained similarly to that for a traditional throat culture, but a RADT "kit" is employed to help determine the presence or absence of the strep bacteria. The turn around time is generally 10 minutes. The RADT is less precise when compared with a throat culture. Most RADT tests are about 95% accurate in determining the presence of strep bacteria. Most guidelines recommend that a negative rapid strep test be confirmed with a throat culture. Of note, antibiotic pretreatment prior to obtaining a throat swab for strep bacteria can interfere with throat culture results, and thus the ability to correctly diagnose and treat a strep throat infection. Antibiotic treatment prior to a rapid strep test is less likely to have a false negative result since the test is designed to document the presence or absence of the GAS bacteria. Residual dead bacteria in the patient may allow a positive result.

    The above tests are designed to determine whether an individual currently has a strep throat infection. Sometimes it may be necessary to determine whether a patient has had a recent history of a strep infection. In that case, two blood tests are available: (a) an ASO (anti streptolysin O) titer, and/or (b) an anti DNase titer. The antibodies that these tests are sensitive to are not commonly present until a few weeks following an acute strep infection. These tests may be ordered when evaluating a patient who may have developed delayed complications (such as rheumatic fever or glomerulonephritis) after a strep throat infection.

    What is the treatment for strep throat?

    Treatment of a strep throat infection includes the use of antibiotics and over-the-counter medications and home remedies for the reduction of symptoms.

    What are home remedies for strep throat?

    There are a number of home remedies that may be used for symptom reduction. They may be used whether the patient has strep throat or a viral cause of their illness. These remedies should not be used in lieu of a complete course of antibiotics if a GAS infection is being treated. Home therapies include:

    • Saltwater gargle: mix ¼ to ½ teaspoon with 8 ounces of warm water. Young children may swallow the solution instead of gargling it and should thus avoid this approach.
    • Hard candies or throat lozenges may be sucked on for effective reduction of symptoms.
    • Ice cream, smoothies, popsicles, cold drinks, and warm tea with honey may be useful to soothe the sore throat. Honey should be avoided in infants less that 1 year of age because of their increased likelihood of botulinum toxicity and paralysis.

    What over-the-counter) OTC drugs are helpful reducing strep throat symptoms?

    Several over-the-counter (OTC) medications, such as acetaminophen (Tylenol) and ibuprofen (Advil and Motrin), can be used to lower the fever and provide pain relief for the sore throat. Aspirin should not be used in children or adolescents because of its association with Reye's syndrome.

    What antibiotics are prescribed to treat strep throat?

    • Antibiotics provide the mainstay for successfully treating a strep throat infection.
    • The GAS bacteria are generally susceptible to the penicillin family (for example, amoxicillin [Amoxil]) and the cephalosporin family (for example, cephalexin [Keflex], cefprozil [Cefzil), cefdinir [Omnicef] and others).
    • Members of the macrolide family (for example, erythromycin [E-mycin], azithromycin [Zithromax] and clarithromycin [Biaxin]) are generally felt to be less effective than the other two classes of antibiotics, but are used in individuals with moderate penicillin or cephalosporin allergy. If such a patient cannot tolerate the macrolide family, clindamycin (Cleocin) is an alternative and very effective antibiotic option.
    • Regardless of what antibiotic is prescribed, it is incumbent to complete the entire course of the antibiotic. A rapid reduction in symptoms within 24 to 48 hours is to be expected. Viral throat infections do not require antibiotics since they provide no benefit.

    What are the potential complications of strep throat?

    The possible complications of strep throat include:

    • Acute rheumatic fever (see below),
    • Glomerulonephritis (see below),
    • Otitis media (middle ear infection),
    • Toxic shock syndrome (a rare but severe complication which may result in the failure of multiple organs and may thus be fatal),
    • Peritonsillar abscess or retropharyngeal abscess (walled off infection containing GAS bacteria and pus which may encroach upon the structures in the back of the throat or invade and rupture into deeper structures which may ultimately be fatal), and PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep) - (see below).

    Acute rheumatic fever (ARF): While rare, this complication of an untreated or inadequately treated strep infection can have devastating and lifelong consequences. It is believed that due to incomplete eradication of the strep bacteria, certain GAS cause an immune response which may attack the joints leading to permanent arthritis. More concerning is the autoimmune response to the heart valves which may damage them and may result in heart failure. Many studies have shown that effective and appropriate antibiotic therapy for strep throat vastly reduces the likelihood of developing ARF.

    Glomerulonephritis: Similar to the aberration of the immune response seen with ARF, autoantibodies may develop to the microscopic filters (glomeruli) of the kidney. This complication more commonly affects children between 7 to 10 years of age. While more common than acute rheumatic fever, glomerulonephritis carries a less ominous prognosis. Helpful therapies exist and most children make a complete recovery and do not experience long-term kidney damage. Unlike ARF, the development of glomerulonephritis is not necessarily prevented by effective antibiotic treatment.

    PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep): Specialists debate the proposed link of a GAS infection in children with the development and/or worsening of obsessive-compulsive behaviors or tic disorder (Tourette's syndrome in the extreme). One area being researched in this controversial condition is whether antibiotic therapy affects the development of or severity of the disorder.

    Source: http://www.rxlist.com

    Treatment of a strep throat infection includes the use of antibiotics and over-the-counter medications and home remedies for the reduction of symptoms.

    Source: http://www.rxlist.com

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