Authors: Jody Ann Maes
Categories: Article
Source: Berman's Pediatric Decision Making
Acute pharyngitis is one of the most common illnesses for which children visit a healthcare facility. Many viruses and bacteria can cause acute pharyngitis in children and adolescents. A partial list of the most common microorganisms that cause pharyngitis in children and adolescent is provided in Table 1 . Group A Streptococcus (GAS) is the most important of the bacterial causes of pharyngitis. It accounts for 15% to 30% of cases of acute pharyngitis. GAS pharyngitis is uncommon in children younger than 3 years and rare in children younger than 15 months.
It is important to identify children with GAS pharyngitis not only for the reasons listed earlier, but to reduce antibiotic use for those children who have a viral cause of pharyngitis (Tables 2 and 3 ).
GAS is a self-limited illness, generally not lasting more than 3 to 5 days, even in the absence of treatment. The main reason to treat GAS pharyngitis is to prevent complications. Complications of GAS pharyngitis
1.Rheumatic fever
Peritonsillar abscess (see Table 4 for features)
Retropharyngeal abscess (abscess formation between the posterior pharyngeal wall and prevertebral fascia; see Table 5 for features)
4.Poststreptococcal no evidence has been reported that treating GAS prevents the development of poststreptococcal glomerulonephritis
A.History and Physical Examination: Some typical features of viral pharyngitis include cough, rhinorrhea, nasal congestion, conjunctivitis, hoarseness, oral/pharyngeal vesicles or ulcers, viral exanthema, and age younger than 3 years. Some typical features of GAS pharyngitis include abrupt onset of fever, throat pain, headache, abdominal pain with or without vomiting, tender anterior cervical lymph nodes, exudative pharyngitis, palatal petechiae, scarlet fever rash, absence of cough, rhinorrhea, nasal congestion, and recent confirmed exposure (especially household). The features of a peritonsillar abscess are important to recognize because it is a frequent complication of pharyngitis. They include prolonged sore throat, severe sore throat, muffled voice, trismus, dysphagia, drooling, asymmetric bulge and enlarged tonsil on affected side, deviated uvula to the contralateral side, and adolescence (peritonsillar abscess is rare in young children). A retropharyngeal abscess is characterized by ill appearance, reluctance to move neck, and often neck swelling, and it usually occurs in younger children.
Evaluation: Although there are signs and symptoms more suggestive of GAS pharyngitis, several studies have demonstrated that the diagnosis of GAS pharyngitis based on clinical signs and symptoms alone even by experienced clinicians is unreliable. Based on these studies, many children who do not have GAS pharyngitis would be treated unnecessarily with antibiotics. Therefore, guidelines from the Infectious Disease Society of America, as well as from the American Academy of Pediatrics (AAP), indicate that microbiologic confirmation either with a throat culture or a Rapid Antigen Detection Test (RADT) is required for the diagnosis of GAS pharyngitis. A throat culture is the gold standard for diagnosis of GAS pharyngitis. If performed correctly, it has a sensitivity of 90% to 95%. The disadvantage of doing a throat culture only is that results may take up to 48 to 72 hours. In addition, many patients with viral pharyngitis are started on antibiotics pending throat culture results, some of which complete a 10-day course anyway. The majority of currently available RADTs have specificities of 95%. However, sensitivity is between 70% and 90%. Throat swabs should be obtained from the surface of both tonsils and the posterior pharyngeal wall. In the more severely ill patients or those you are concerned may have complications, a complete blood cell count and blood culture may be useful. A computed tomographic scan of the neck may also be indicated (Table 6 ).
Treatment of GAS Pharyngitis: GAS remains universally sensitive to penicillin and is currently recommended by the AAP as first-line therapy for GAS pharyngitis secondary to its narrow spectrum and low cost. The disadvantage of oral penicillin is that it must be taken for 10 days. Amoxicillin is a low-cost alternative and is often preferred to penicillin because it tastes better than penicillin. In addition, several studies have demonstrated that amoxicillin given as a single daily dose is as effective as orally administered penicillin given for 10 days. A myriad of other drugs treat GAS pharyngitis, including cephalosporins, macrolides, erythromycin, and clindamycin. Erythromycin or azithromycin can be used for patients allergic to penicillin. Cephalosporins are also acceptable in penicillin-allergic patients, except for patients with an immediate or type 1 hypersensitivity to penicillin. A short-course regimen of 5 to 7 days with several cephalosporins has been shown by several studies to produce a bacteriologic eradication rate similar to a 10-day course of penicillin. However, only azithromycin and cefpodoxime have been approved by the U.S. Food and Drug Administration as a 5-day treatment course for GAS pharyngitis. Although a shorter course therapy is associated with increased compliance, most of these antibiotics are significantly more expensive than penicillin or amoxicillin. Penicillin-resistant strains of GAS have never been identified. Therefore, treatment failure is not likely secondary to penicillin resistance. The causes of treatment failure are unrecognized carrier state (with repeated episodes of viral pharyngitis), poor compliance with prescribed therapy, or reinfection. Another possible cause is suppression of immunity with prompt antibiotic treatment. Antibody suppression has been associated with relapse and recurrence of GAS pharyngitis.
An algorithm is included on the evaluation and treatment of a peritonsillar abscess.