Stony Brook Children S Pediatric Primary Care Clinic Curriculum

Stony Brook Children’s Pediatric Primary Care Clinic Curriculum Pharyngitis February 2016 Materials developed by Susan Walker, MD

Goal: To become competent at the diagnosis and treatment of pharyngitis in children Objectives: 1. Understand the different causes of pharyngitis, viral and bacterial, and how to distinguish between them 2. Understand the clinical indications for group A streptococcal pharyngitis testing 3. Chose appropriate antibiotic therapy for group A streptococcal pharyngitis 4. Distinguish between acute infection with and carrier state of group A streptococcus

ABP content specs: Throat Understand the natural history of viral infections of the throat Tonsillitis, pharyngitis Plan the appropriate diagnostic evaluation of tonsillitis/pharyngitis Plan the appropriate management of tonsillitis/pharyngitis, including when culture results remain positive following initial therapy Formulate a differential diagnosis of exudative tonsillitis/pharyngitis Streptococcus pyogenes (group A streptococcus) Understand the epidemiology of Streptococcus pyogenes Plan the appropriate diagnostic evaluation of suspected Streptococcus pyogenes infection Recognize the clinical features associated with Streptococcus pyogenes infection Recognize the complications associated with invasive and non-invasive Streptococcus pyogenes infection Plan appropriate management for a patient with Streptococcus pyogenes infection

Readings:

1. “Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America” Stanford T. Shulman et. Al., Infectious Diseases Society of America. Clin Infect Dis. 2012 http://www.idsociety.org/uploadedFiles/IDSA/Guidelines- Patient_Care/PDF_Library/2012%20Strep%20Guideline.pdf

2. “Principles of Judicious Antibiotic Prescribing for Bacterial Upper Respiratory Tract Infections in Pediatrics” Adam L. Hersh, Mary Anne Jackson, Lauri A. Hicks, the COMMITTEE ON INFECTIOUS DISEASES. Pediatrics, 2013 (good review, for the purpose of this months’ assignment focus on the section about pharyngitis) http://pediatrics.aappublications.org/content/early/2013/11/12/peds.2013-3260

Pharyngitis Questions

1. All of the following are reasons to treat a patient with group A streptococcal pharyngitis (GAS) EXCEPT: A. To reduce the clinical severity of infection B. To prevent the development of acute rheumatic fever C. To prevent the development of acute post-streptococcal glomerulonephritis D. To reduce the transmission of infection to other individuals E. All of the above are reasons to treat

2. The antibiotic of choice to treat GAS pharyngitis in a patient with no known drug allergies is: A. Azithromycin B. Cefdinir (Omnicef) C. Clarithromycin D. Penicillin E. Ceftriaxone

3. All of the following are reasons to perform confirmatory throat culture for a patient with a negative rapid antigen detection test (RADT) EXCEPT: A. RADTs have a specificity of 95% B. RADTs have a sensitivity of less than 90% C. The proportion of acute pharyngitis in children due to GAS is 20-30% D. Throat culture is the gold standard for diagnosis of GAS

4. The reason to treat non-group A (group C or G) streptococcal pharyngitis is: A. To prevent the development of acute rheumatic fever B. To reduce the clinical impact of the illness C. It is the most common bacterial cause of pharyngitis D. To prevent the development of post-streptococcal glomerulonephritis

5. List the Centor criteria for diagnosis of group A streptococcal pharyngitis:

Pharyngitis Cases

You are in your clinic seeing a four-year-old boy who woke with a sore throat and tactile warmth yesterday. Today, he has developed a runny nose, a barking cough, and hoarse voice. Physical exam is significant for an erythematous pharynx and clear nasal discharge. What are the components of the history that point toward viral pharyngitis as opposed to streptococcal pharyngitis?

His mother informs you that she has heard that “strep throat” is going around in her older daughter’s 3rd grade class. She asks you to “test him for strep.” What do you tell her?

The mom leaves the office reassured that her son has a viral syndrome. Two weeks later, she returns with her 8-year-old daughter, who had acute onset of throat pain and fever of 102F yesterday evening. Today, she complains of a headache and abdominal pain. She has no congestion or cough. Physical exam is significant for a temperature of 101F, beefy red pharyngeal erythema and tonsillar exudates. What components of the history and physical point to group A streptococcal pharyngitis as the diagnosis?

This case seems like classic streptococcal pharyngitis; do we really need to test?

You perform a rapid antigen detection test (RADT) for group A streptococcus. The test is positive. What antibiotic will you use to treat this patient?

What if she were penicillin-allergic?

The mother wonders if you are “sure” that this is strep. What do you tell her?

The mom holds out her 7-month-old infant. “He’s been cranky lately, could he have strep too?” How do you respond?

As you are leaving the room, you hear the mother tell her daughter; “This is the second time you’ve had strep this year. Maybe you’re a carrier!” Your thoughts?

As you are walking by the front desk, you overhear the mother making an appointment for her daughter for next week “to make sure the strep is gone.” You intercept the clerk and cancel the appointment. Why?