DR.T.V.RAO MD 1

Dr.T.V.Rao MD

STREPTOCOCCAL PHARYNGITISCOMPLICATIONS, DIAGNOSIS, PREVENTION

GROUP A STREPTOCOCCAL INFECTION AND HEALTH CARE- TRIBUTE TO

IGNAZ SEMMELWEIS

Ignaz Philipp Semmelweis

(1818-1865)

All students or doctors who enter the wards for the purpose of making an examination must wash their hands thoroughly in a solution of chlorinated lime which will be placed in convenient basins near the entrance of the wards. This disinfection will be considered sufficient for this visit. Between examinations the hands must be washed in soap and water.

1847

DR.T.V.RAO MD 3

DEFINITIONSPharyngitis refers to inflammation of the

structures of the pharynx.

- The tonsils are most often affected.

- The term pharyngitis, tonsillitis, tonsillopharyngitis and pharyngotonsillitis are interchangeable and do not imply an etiology.

STREPTOCOCCUS PYOGENES:MICROSCOPIC APPEARANCE & COLONIAL MORPHOLOGY

INFECTIONS CAUSED BY STREPTOCOCCUS PYOGENES (GAS)

• Superficial diseasespharyngitis, skin & soft tissue infn, erysipelas,

impetigo, vaginitis, post-partum infn

• Deep infectionsbacteraemia, necrotising fasciitis, deep soft

tissue infn, cellulitis, myositis, puerperal sepsis,

pericarditis, meningitis, pneumonia, septic

arthritis

• Toxin-mediatedscarletina, toxic shock-like syndrome

• Immunologically mediatedrheumatic fever, post-streptococcal GN,

reactive arthritis

GROUP A STREPTOCOCCAL INFECTION OVERALL DISEASE BURDEN

Each year• 1.8 million new cases of serious infection• at least 500,000 deaths • 110 million cases of soft tissue infection • 610 million cases of pharyngitis

At least 18 million people suffer the consequences of serious GAS diseases

DR.T.V.RAO MD 7

DEFINITIONS• Pharyngitis

• predominantly inflammation of the oropharynx, but not the tonsils.

• Tonsillitis• when the tonsils are particularly affected.

• Laryngitis• few signs of infection visible but the patient complains of

soreness lower down the throat often with a hoarse voice.

DR.T.V.RAO MD 8

STREP THROAT

• Strep throat is caused by Group A Streptococcus bacteria. It is the most common bacterial infection of the throat Streptococcal pharyngitis, streptococcal tonsillitis, or streptococcal sore throat (known colloquially as strep throat) is a type of pharyngitis caused by a group A streptococcal infection It affects the pharynx including the tonsils and possibly the larynx. Common symptoms include fever, sore throat, and enlarged lymph nodes. It is the cause of 37% of sore throats among children

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1. Which factors lead to the spread of GAS pharyngitis? Droplets, Not Fomites, Overcrowding, Possibly families with young children, Proven family contacts, and the effects of poverty

HOW THE GROUP A STREPTOCOCCI SPREAD

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• 30%-65%: idiopathic• 30%-60%: viral• 5%-10%: bacterial• Group A beta-hemolytic:

most common bacterial pathogen

• 15%-36%: pediatric cases

• 5%-10% : adult pharyngitis

• Disease of children

ETIOLOGY

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PROGRESS OF EVENTS IN GROUP A STREPTOCOCCAL INFECTION

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WHICH CLINICAL SIGNS AND SYMPTOMS BEST CORRELATE WITH GROUP A STREPTOCOCCAL (GAS) PHARYNGITIS INFECTION

IN ADULTS AND CHILDREN?1. Temperature > 38 C

2. Sudden onset

3. Coryza

4. Diarrhoea

5. Macular rash

6. Age 3 -14 yrs

7. Conjunctivitis

8. Early winter or spring presentation

9. Exudate on tonsils

10. History of exposure to GAS

11. Palpable cervical lymph nodes

12. Cough

13. Myalgia

14. Prolonged sore throat

15. Fatigue

16. No cough

17. Sandpaper-like rash

18. Nausea

19. Loss of appetite

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DIAGNOSIS

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COLLECTING A APPROPRIATE SPECIMEN IS HIGHLY ESSENTIAL

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• AVOID TOUCHING THE TONGUE AND LIPS.

• SWAB FROM EXUDATE AND BOTH TONSILS.

• ALSO POST PHARYNGEAL WALL – BEHIND THE UVULA AND BETWEEN THE TONSILS.

COLLECTING PHARYNGEAL SPECIMEN

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THROAT CULTURE: GOLD STANDARD

• Throat culture: gold standard for treating

• Sensitivity 90%, specificity 99%

• American Academy of Pediatrics, US Centers for Disease Control and Prevention and Infectious Diseases Society of America- GABHS test prior to treating children with suspected strep pharyngitis

• For adult patients to confirm clinical diagnosis

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UNDERSTANDING THE IMPORTANCE OF THROAT CULTURING

• A throat culture is the gold standard for the diagnosis of streptococcal pharyngitis with a sensitivity of 90–95%. ] A rapid strep test (also called rapid antigen detection testing or RADT) may also be used. While the rapid strep test is quicker, it has a lower sensitivity (70%) and statistically equal specificity (98%) as throat culture.

• A positive throat culture or RADT in association with symptoms establishes a positive diagnosis in those in which the diagnosis is in doubt.[ Asymptomatic individuals should not be routinely tested with a throat culture or RADT because a certain percentage of the population persistently "carries" the streptococcal bacteria in their throat without any harmful results. [

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OBSERVATION OF STREPTOCOCCUS GROUP A ON SHEEP BLOOD AGAR PLATES

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LIMITATIONS IN DIAGNOSIS• Throat swabs cannot differentiate between "infection"

and "carriage", are poorly sensitive, and are therefore of limited value. Results take up to 24 - 48 hours to be reported, and the test is relatively expensive.

• Rapid antigen tests to detect streptococcal antigen on a throat swab are not easily available.

• Anti-streptolysin O (ASO) titres can help to identify whether a patient has recently been infected with streptococcus, and may be useful for patients who remain unwell or develop complications.

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• Infectious mononucleosis (glandular fever)

• Epiglottitis (requires urgent admission)

• Gonococcal pharyngitis (rare)

• Diphtheria (very rare in developed countries )

• Neutropenia (e.g. ensure patient not on carbimazole)

DIFFERENTIAL DIAGNOSIS

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STREPTOCOCCUS GROUP A INFECTIONS CAN BE SELF LIMITING

• Group A strep pharyngitis naturally self-limiting• Resolve spontaneously in 3-4 days w/ or w/o

antibiotics• Rapid test or throat culture: reduces

unnecessary antibiotic use by identifying those whom antibiotic therapy is justified

• Viral etiology do not need antibiotic treatment

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• Otitis media

• Sinusitis

• Peritonsillar abscess (quinsy)

• Suppurative cervical adenopathy

• Rheumatic fever

• Post streptococcal glomerulonephritis

COMPLICATIONS OF STREPTOCOCCAL INFECTION

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• Complications arising from streptococcal throat infections include:

• Acute rheumatic fever

• Scarlet fever

• Streptococcal toxic shock syndrome]

• Glomerulonephritis]

• PANDAS syndrome]

COMPLICATION OF STREPTOCOCCAL INFECTIONS

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WHAT IS PANDAS• PANDAS is an acronym for Paediatric Autoimmune

Neuropsychiatric Disorders Associated with Streptococcal infections. This term describes a hypothesis that a set of children develop rapid onset of obsessive-compulsive disorder (OCD) and/or tic disorders following group A beta-haemolytic streptococcal (GABHS) infections such as "strep throat" and scarlet fever. The proposed link between infection and these disorders is an autoimmune reaction, where antibodies produced to the infection interfere with neuronal cells.

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STREPTOCOCCAL GROUP A INFECTIONS CAN PRODUCE RHEUMATIC HEAR DISEASE AND

GLUMORELONEPHRITS

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MANAGEMENT • If an antibiotic is necessary

• Penicillin is the treatment of choice, with erythromycin in patients with penicillin allergy. 10 days treatment is recommended in order to eradicate possible streptococcus infection. [DTB 1995]

• Tonsillectomy is occasionally recommended for recurrent attacks of tonsillitis. Consider only if seven documented throat infections in the preceding year, or three in each of three successive years.

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ERADICATIONS OF STREPTOCOCCUS WILL REDUCE THE COMPLICATIONS

• Eradication of GABHS to provide primary prevention against suppurative and nonsuppurative complications

• Abating clinical signs and symptoms• Reducing bacterial transmission to close

contacts• Minimizing adverse effects of therapy• Early abx tx: shortens clinical course

DR.T.V.RAO MD 28

PREVENTION• Most people with strep are contagious until they have been on

antibiotics 24 - 48 hours. They should stay home from school, day-care, or work until they have been on antibiotics for at least a day.

• Get a new toothbrush after you are no longer contagious, but before finishing the antibiotics. Otherwise the bacteria can live in the toothbrush and re-infect you when the antibiotics are done. Also, keep your family's toothbrushes and utensils separate, unless they have been washed.

• If repeated cases of strep still occur in a family, you might check to see if someone is a strep carrier. Carriers have strep in their throats, but the bacteria do not make them sick. Sometimes, treating them can prevent others from getting strep throat.

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