key: cord-0040424-b7nk1zpn
authors: Ann Maes, Jody
title: Acute pharyngitis in children
date: 2011-07-28
journal: Berman's Pediatric Decision Making
DOI: 10.1016/b978-0-323-05405-8.00046-2
sha: e9fb1aa84c1c880b0bcd0bb9c8479ff6edeca063
doc_id: 40424
cord_uid: b7nk1zpn

nan

1. Prevent acute rheumatic fever (ARF): Although the incidence of ARF is rare, significant sequelae are associated with ARF. Children younger than 4 years are not usually at risk for ARF. Treatment begun up to 9 days after GAS infection prevents ARF. 2. Prevent suppurative sequelae (peritonsillar, retro pharyngeal abscess). 3. Shorten the duration of symptoms. 4. Interrupt transmission to family member or classmates.

It is important to identify children with GAS pharyngitis not only for the reasons listed earlier, but to reduce anti biotic use for those children who have a viral cause of pharyngitis (Tables 2 and 3 ).

GAS is a selflimited 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 compli cations. Complications of GAS pharyngitis are:

1. Rheumatic fever 2. Peritonsillar abscess (see Table 4 for features) 3. Retropharyngeal abscess (abscess formation between the posterior pharyngeal wall and prevertebral fascia; see Table 5 for features) 4. Poststreptococcal glomerulonephritis: no evidence has been reported that treating GAS prevents the development of poststreptococcal glomerulone phritis 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 ante rior cervical lymph nodes, exudative pharyngitis, palatal petechiae, scarlet fever rash, absence of cough, rhinor rhea, 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 pro longed 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. B. Evaluation: Although there are signs and symptoms more suggestive of GAS pharyngitis, several studies have dem onstrated 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 Amer ica, 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 10day 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 complica tions, a complete blood cell count and blood culture may be useful. A computed tomographic scan of the neck may also be indicated (Table 6 ).

C. Treatment of GAS Pharyngitis: GAS remains univer sally sensitive to penicillin and is currently recom mended by the AAP as firstline therapy for GAS phar yngitis 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 lowcost alternative and is often preferred to penicillin because it tastes bet ter 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 peni cillin. Cephalosporins are also acceptable in penicillin allergic patients, except for patients with an immediate or type 1 hypersensitivity to penicillin. A shortcourse regimen of 5 to 7 days with several cephalosporins has been shown by several studies to produce a bacterio logic eradication rate similar to a 10day course of penicillin. However, only azithromycin and cefpodox ime have been approved by the U.S. Food and Drug Administration as a 5day treatment course for GAS pharyngitis. Although a shorter course therapy is asso ciated with increased compliance, most of these antibi otics are significantly more expensive than penicillin or amoxicillin. Penicillinresistant 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 com pliance 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. D. An algorithm is included on the evaluation and treat ment of a peritonsillar abscess. 

Evaluation of sore throat in children

Principles and practices of pediatric infectious diseases

Group A Streptococcal infections

Group A betahemolytic Streptococcal Infections