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.] - Five days of penicillin 250 QID: didn't work as well as 10 days. - 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.