Strep Throat ============ þ Macrolide-resistant Group A Strep - Study at Children's in Pgh found 38% of Group A strep was hightly resistant to macrolides - Mercy pharmacy recomends for those with delayed PCN hypersensitivity a cephalosporin, and for those with more serious reactions, clinda. (2/02) þ Scarlatina (Scarlet Fever) þ Strep Throat Diagnosis - Single plate culture same for diagnosis as rapid strep tests. - Family physicians overestimated strep in 81%. - Rare if over age 30. - Rapid Strep: 79-88% sensitive, 90-96% specific - 20-65% neither viral or bacterial. - Walsh Method: clinical scale, culture only if more than 10. Degree > 36.1 3 pts. Exudate 6 pts Nodes 11 pts GAS 17 pts cough -7 pts - Centor Criteria: + History of fever + absence of cough + presence of exudates + tender anterior nodes [Centor RM, Witherspoon JM, Dalton AP, et. al. The diagnosis of strep throat in adultsin the emergency room. Med Decis Making 1981;1:239-246.] þ Strep Throat Treatment Effectiveness - Effectiveness: about 10-30% will have strep culturable from their throats a few months later, even with good compliance with treatment. Failure rate for any form of penicillin (IM or PO) has risen from 8% 30 years ago to about 25% now. Some suggest this is due to beta lactamase produced by other nearby bacteria. {Kaplan EL. Benzathine penicillin G for treatment of group A streptococcal pharyngitis: a reappraisal in 1985. Pediatr Infect Dis J 1985; 4(5):592.} Allergic reactions to Benzathine Penicillin G are usually transient. {Markowitz. Clin Ther 1980; 3:49} Dosage of Benzathine Pen G: Under 27 kg 600,000 u; over 27kg 1.2 million units IM (per Sanford). - Noncompliance is a problem with any oral medication. þ Recurrent strep tonsillitis - many studies suggest that treatment with drugs effective against penicillinase-producers (e.g., Duricef, as described below) have a lower recurrence rate. þ Strep Treatment Regimes: - Penicillin one gram PO BID: Same clinical cure rate (100%) and same laboratory cure rates (94-96%). However, people got better a day quicker with 1g BID, and had less risk of cross-infection. [Helleman K. Pulse dosing with penicillin V in streptococal pharyngitis: 1000 mg BID vs. 250 mg QID. Current Therapeutic Research 1978; 43(3):374.] [Rev Infect Dis 1981; 3:1.] [Dajani AS, et al. Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever: American Heart Association. Pediatrics 1995;96:758.] - PCN 250 BID worked as well as 250 mg TID [Gerber, M. A., L. J. Spadaccini, et al. (1985). "Twice-daily penicillin in the treatment of streptococcal pharyngitis." Am J Dis Child 139(11): 1145-1148.] An investigation was performed to compare the effectiveness of oral penicillin V given twice daily with penicillin V given three times daily in the treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis. Patients were randomly assigned to receive 250 mg of penicillin V either two or three times daily for ten days. Overall, 23 (23%) of 99 patients had the same strain of GABHS isolated from their follow-up as from their initial throat culture and were considered to have bacteriologic-treatment failures. Of the 50 patients in the three-times-daily group, nine (18%) had bacteriologic-treatment failures, while 14 (28.5%) of 49 patients in the twice-daily group had bacteriologic-treatment failures. The results of this and earlier investigations suggest that penicillin V given twice daily is as effective as penicillin V given three times daily for the treatment of GABHS pharyngitis. - PCN 500 BID is recommended for kids, better than 1000 mg daily or 250 mg QID [Krober, M. S., M. R. Weir, et al. (1990). "Optimal dosing interval for penicillin treatment of streptococcal pharyngitis." Clin Pediatr (Phila) 29(11): 646-648.] One-hundred-forty-two children with symptomatic pharyngitis had throat cultures positive for group A beta-hemolytic streptococci (GABHA). All were treated orally with penicillin V for ten days. Patients were randomly assigned to receive daily doses of 250 mg four times daily, 500 mg twice daily, or 1000 mg once daily. They were followed four weeks for either recurrent symptomatic pharyngitis or asymptomatic repeat positive throat culture. Patients treated two or four times daily had comparable outcomes. Children given penicillin once daily were more likely to have persistent positive culture after 48 hours treatment (5 of 48 or 10.4% vs. none of 94, p = .004) and more likely to have recurrent positive cultures after end of treatment (10 of 43 or 23% vs. 8 of 94 or 8%, p = .04). The treatment regime of penicillin V 500 mg twice daily is recommended for treatment of pharyngitis due to GABHS. - Five days of penicillin 250 QID: didn't work as well as 10 days. [Gerber, M. A., M. F. Randolph, et al. (1987). "Five vs ten days of penicillin V therapy for streptococcal pharyngitis." Am J Dis Child 141(2): 224-227. To determine the effectiveness of a short (five-day) course of penicillin V potassium therapy, 172 patients with group A beta-hemolytic streptococcal (GABHS) pharyngitis were randomly assigned to receive 250 mg of penicillin V potassium three times daily for either five or ten days. The patients in the two treatment groups were comparable with respect to clinical findings, compliance, and serologic response to GABHS. A bacteriologic treatment failure was defined as the presence of the same serotype of GABHS in the follow-up as in the initial throat culture and occurred in 13 (18%) of the 73 patients in the five-day treatment group and in six (6%) of the 99 patients in the ten-day treatment group. These findings support the current recommendation for a full ten days of oral penicillin V therapy for the treatment of GABHS pharyngitis. - Cefadroxil (Duricef) (1g daily) instead of penicillin: worked well. {Stromberg A et al. Five vs. ten day treatment of group A streptococcal pharyngotonsillitis: a randomized controlled clinical trial with phenoxymethyl penicillin and cefadroxil. Scand J Infect Dis 1988; 20:37.} {Goldfarb J et al. Once daily cefadroxil vs. oral penicillin in the pediatric treatment of streptococcal pharyngitis. Clin Ther 1988; 10(2):178.} {Gerber MA. Comparison of cefadroxil and penicillin V in the treatment of streptococcal pharyngitis in children. Drugs 1986; 32:29.} - Seven days of penicillin: not as good as 10. {Schwartz. JAMA 1981; 246:1790.} - Some argue for using a cephalosporin for first-line treatment of strep; one author argues for cephalexin because it is cheap and safe, even though his own particular study was on cefaclor (Ceclor). {Stillerman M. comparison of oral cephalosporins with penicillin therapy for Group A streptococcal pharyngitis. Pediatr Infec Dis 1986; 5:649.} - Up to 60% of strep in some countries is resistant. þ Strep Complications: Rheumatic Fever, Glomerulonephritis - 0.5% of those with strep will go on to have rheumatic fever. - 1/3 of those with RF remember no sore throat, 1/3 remember a ST that was appropriately treated, 1/3 untreated ST.