Strep pharyngitis

Continuity Clinic Case of the Week 10/8/2012

An established 5 year-old patient presents to your busy afternoon clinic with fever of 102, decreased eating and complaints of mouth and throat pain. Per his mother, there has been no runny nose and only an occasional cough. Since you are an hour behind, an efficient medical assistant has run a rapid strep test and it is positive. R1: R2/3: In a previous encounter, this patient was prescribed amoxicillin and developed hives. What is the most appropriate antibiotic choice? The mother asks about treating her other children. She has a 6 month old who is fussier than normal and an 8 year old who lives with her ex-husband who is currently having cough, runny nose and a temp of 100.4. Neither other child has a drug allergy. The most appropriate action would be: A. Treat both children with amoxicillin B. Treat the younger child who lives in the household with amoxicillin and do not treat the older child. o C. Treat the older child. o D. Advise the mother than neither child needs to be treated at this point. 1 month later, your patient returns to clinic with fever and sore throat again. Another rapid strep test is performed and is positive. At this point: o A. He needs to be treated with a different antibiotic o B. Another course of the same antibiotic is appropriate o C. He should be referred to ENT for tonsillectomy o D. He needs to have imaging to rule-out an abscess o o Should this patient have had a rapid strep done? Does a back-up culture need to be sent to confirm antibiotic susceptibility?

R1: Should this patient have had a rapid strep done? Yes His symptoms arent suggestive of a viral infection (no runny nose, significant cough, hoarseness, oral ulcers). One suggestion is to use the following scoring system to help determine likelihood of strep.

Does a back-up culture need to be sent to confirm the rapid strep and ensure antibiotic susceptibility? No rapid strep tests (RADTs) are highly specific (>95%) so false positives are highly unusual. Antimicrobial resistance has not been a significant issue in the treatment of GAS. No clinical isolate of GAS has demonstrated penicillin resistance, likely due to the organism's lack of altered penicillin-binding proteins and/or inefficient gene transfer mechanisms for resistance. A meta-analysis of 51 studies showed no significant difference in the bacteriologic failure rate associated with penicillin treatment between the period from 1953 to 1979 and the period from 1980 to 1993 (10.5% and 12%, respectively).

R2/3: In a previous encounter, this patient was prescribed amoxicillin and developed hives. What is the most appropriate antibiotic choice? Treatment in penicillin allergic individuals without anaphylaxis can be done with a first generation cephalosporin for 10 days. Alternatives would be clindamycin for 10 days,

clarithromycin for 10 days or azithromycin for 5 days (important to note: azithromycin dose is 12 mg/kg per day for 5 days in children less than 27 kg) The mother asks about treating her other children. She has a 6 month old who is fussier than normal and an 8 year old who lives with her ex-husband who is currently having cough, runny nose and a temp of 100.4. Neither other child has a drug allergy. The most appropriate action would be: A. Treat both children with amoxicillin B. Treat the younger child who lives in the household with amoxicillin and do not treat the older child. C. Treat the older child. D. Advise the mother than neither child needs to be treated at this point.

1 month later, your patient returns to clinic with fever and sore throat again. Another rapid strep test is performed and is positive. At this point: A. He needs to be treated with a different antibiotic B. Another course of the same antibiotic is appropriate C. He should be referred to ENT for tonsillectomy D. He needs to have imaging to rule-out an abscess