Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Streptococcal Pharyngitis
An acute pharyngitis is seen in approximately 8% to 30% of all children who present with fever and pharyngeal irritation. It is one of the most common bacterial infections in children.
I. Etiology: Group A beta-hemolytic Streptococcus (GABHS) (S. pyogenes)
II. Incidence
A. Occurs most commonly in mid-winter to spring
B. Uncommon in children younger than 2 years
C. Seen in approximately 8% to 30% of children and 5% to 9% of adolescents who present with a sore throat.
III. Incubation period: 1 to 3 days
IV. Communicability
A. Weeks or months without treatment
B. Generally noninfectious within 24 hours once treatment has started
C. Spread by droplet infection
V. Subjective data
A. Acute onset of sore throat
B. Fever: 102F to 104F (39C to 40C)
C. Vomiting; abdominal pain
D. Listlessness
E. Dysphagia
F. Voice thick or muffled, not hoarse
G. Anorexia
H. Urticaria
I. History of exposure to streptococcal pharyngitis
J. May have few presenting symptoms
VI. Objective data
A. Typical clinical findings
1. Elevated temperature
2. Tonsils and pharynx intensely erythematous
3. Purulent, yellowish exudate on tonsils
4. Petechiae or “doughnut lesions” (raised red lesions with pale centers) on soft palate
5. Edematous, “beefy” red uvula
6. Anterior cervical nodes enlarged and tender
7. May have concurrent otitis media
8. Infant may present with excoriated nares.
B. Do not examine throat of child who is toxic, drooling, sits with head thrust forward, and has stridor. Child may have acute epiglottitis.
C. May not present with typical picture
1. A throat culture should be done to confirm or deny diagnosis of GABHS in any child with pharyngitis.
2. Note: This author has seen many instances when the presenting complaint has been an urticarial rash with no history of pharyngitis. However, when examining the child and finding erythema of the anterior pillars, I found a markedly positive rapid strep test result for group A streptococci.
VII. Assessment
A. Diagnosis
1. Rapid Direct Antigen Test (DAT) or throat culture positive for GAS
2. Note: Current data on rapid strep tests suggest that the specificity is 95% to 99% and the sensitivity ranges from 85% to 95% and higher when more than 10 colonies of streptococci are present.
3. If the rapid strep DAT is negative, an accompanying conventional throat culture should be done.
4. Most children strenuously object to having a throat swab done. To avoid having to repeat the swab if the rapid strep test is negative, when performing a throat swab, do two simultaneously.
B. Differential diagnosis
1. Viral pharyngitis: Negative rapid strep or negative throat culture
2. Infectious mononucleosis: Positive heterophil antibody or Monospot test; more generalized adenopathy, tonsillar exudate generally thicker and whiter; 20% of children with infectious mononucleosis will have a concurrent streptococcal pharyngitis.
3. Epiglottitis: Toxic, dysphagic, drooling, stridor
VIII. Plan
A. Penicillin V: Less than 27 kg, 250 mg 2–3 times a day for 10 days More than 27 kg, 500 mg 2–3 times a day for 10 days
B. If allergic to penicillin, erythromycin ethylsuccinate: 40 mg/kg/d in 2–4 divided doses for 10 days; 250 mg 4 times a day for children over 20 kg (maximum dosage 1 gm/d)
C. Acetaminophen for elevated temperature, headache, and general discomfort, 10 to 15 mg/kg every 4 hours
D. Warm saline gargles
E. Treat contacts at-risk (e.g., child who has had rheumatic fever).
F. Cephalosporins are effective in the treatment of streptococcal pharyngitis. Penicillin, however, is safe, inexpensive, and is the one agent proven in controlled studies to prevent acute rheumatic fever.
IX. Education
A. Medication
1. Clinical manifestations subside in 3 to 5 days without medication. Treatment reduces duration of symptoms, shortens contagion, and reduces risk of complications.
2. Antibiotic must be given 4 times a day for 10 consecutive days without fail.
3. Give penicillin G 1 hour before or 2 hours after meals.
4. Continue antibiotic, even if child seems better.
5. Side effects of medication include nausea, vomiting, diarrhea, and rashes (maculopapular to urticarial).
B. Isolation is unnecessary after 24 hours of antibiotic therapy.
C. Clinical improvement is generally noted within 24 hours after initiating treatment.
D. Do not send child back to school until temperature has been normal for 24 hours. Child may then resume normal activities.
E. Force fluids
1. Try Popsicles, sherbet, Jell-O, apple juice
2. Avoid orange juice and carbonated beverages; they may be difficult for child to swallow.
3. Do not be concerned about solid foods.
F. Sucking hard candies may help to relieve discomfort of sore throat.
G. Expect child to improve within 48 hours once on medication.
H. Immunity is not conferred, but some resistance is built up.
I. Streptococcal pharyngitis is transmitted by direct or close contact.
X. Follow-up
A. Call immediately if any symptoms of adverse reaction to medication.
B. Call immediately if child unable to retain medication; return to office for IM medication.
C. Call back if child is not improved within 48 hours.
D. Call immediately if other family members complain of sore throat. Those with symptoms should have a throat culture.
E. Call if after 7 to 14 days, child complains of malaise, headache, fever, anorexia, abdominal pain, edema, dark urine, decreased urinary output, or migratory joint pains.
F. Post-treatment throat cultures are indicated for patients at high-risk for rheumatic fever or who still are or are again symptomatic. Follow-up should include a careful cardiac examination and a urinalysis.
G. Follow-up throat culture and eradication of carrier state indicated when
1. Family has a history of rheumatic fever.
2. “Ping-pong” spread of GAS has occurred within a family.
3. Outbreaks occur in closed or semi-closed communities.
4. Tonsillectomy is considered because of chronic GAS.
5. Family is inordinately anxious about GABHS.
6. Treatment for eradicating carrier state
a. Rifampin 20 mg/kg every 24 hours for 4 doses during the last 4 days of penicillin therapy
b. Oral clindamycin 20 mg/kg/d in 3 divided doses for 10 days (maximum 1.8 g/d)
XI. Complications: Complications and sequelae are less likely to occur if treatment is instituted early. However, they may occur despite early, vigorous treatment.
A. Otitis media
B. Pyoderma
C. Cervical adenitis
D. Rheumatic fever (risk approximately 0.3%)
E. Acute glomerulonephritis (risk 10% to 15% if infecting strain nephritogenic)
XII. Consultation/referral
A. Prolonged course
B. Any signs of peritonsillar abscess (e.g., asymmetrical swelling of tonsils, uvula shifted to one side, edema of palate)
C. Any signs or symptoms of acute glomerulonephritis or rheumatic fever
D. Frequent recurrences of strep pharyngitis