Streptococcal pharyngitis: Wikis


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Streptococcal pharyngitis
Classification and external resources
ICD-10 J02.0
ICD-9 034.0
DiseasesDB 12507
MedlinePlus 000639
eMedicine med/1811

Streptococcal pharyngitis or streptococcal sore throat (known colloquially as strep throat in American English) is a form of group A streptococcal infection[1] that affects the pharynx and possibly the larynx and tonsils. It is a very contagious infection, spread by close contact with an infected individual, which can lead to various other complications if not swiftly treated. Antibiotics can help reduce contagiousness.


Signs and symptoms

Streptococcal pharyngitis usually appears suddenly with severe sore throat pain that may make talking or swallowing painful.

Signs and symptoms may include

  • Inflamed tonsils
  • White spots on the tonsils[2]
  • Difficulty swallowing (dysphagia)
  • Tender cervical lymphadenopathy
  • Bumps, bruises, inflamation, or swelling; (goose eggs), on the right, or uncommonly left side of neck.
  • Fever
  • Headache (often prior to other symptoms)
  • Malaise, general discomfort, feeling ill or uneasy
  • Halitosis
  • Abdominal pain, nausea and vomiting[3]
  • Rash[4]
  • Hives
  • Chills
  • Loss of appetite
  • Ear pain
  • Peeling of skin on hands and feet
  • Ears locking up

Additional symptoms such as sinusitis, vaginitis, or impetigo may be present if the strep bacteria infects both the throat and a secondary location. For additional information on non-pharynx symptoms, see Group A Streptococcal (GAS) Infection.


There are several causes for pharyngitis, not just streptococcus bacteria. Productive coughing, nasal discharge, and red, irritated eyes in addition to fever and sore throat are more indicative of a viral sore throat than of strep throat, though a co-infection with a virus is possible and may explain the presence of these additional symptoms. A rapid strep test (also called rapid antigen detection testing or RADT) or a throat culture may be undertaken to clarify diagnosis. The rapid strep test is quicker but less sensitive and specific than a throat culture developed on a blood agar plate.[5] Positive tests in association with symptoms establish a positive diagnosis, which can be treated with antibiotics.[5] Asymptomatic patients should not be routinely tested with a throat culture because a certain percentage of the population persistently "carries" strep throat.[5]

The presence of marked lymph node enlargement along with sore throat, fever and tonsillar enlargement may also occur in infectious mononucleosis (glandular fever).[6]

A study of 729 patients with pharyngitis, in which 17% had a positive throat culture for group A streptococcus, identified the following four best predictors of streptococcus, also called the Centor criteria:[7]

Number of symptoms Probability of Strep
0 2.5%
1 6.0 - 6.9%
2 14.1 – 16.6%
3 30.1 – 34.1%
4 55.7%

Another study on 621 patients, assigned one point for each of the following symptoms:[9]

  • Temperature greater than 38°C (100.4°F)
  • Absence of cough
  • Tender anterior cervical adenopathy
  • Tonsillar swelling or exudate
  • Age younger than 15
  • Subtracting a point for age older than 45.
Points Probability of Strep Management
1 or less 0% Negative: No antibiotic
2 17% Indeterminate: antibiotic based on throat culture
3 35%
4 or 5 51% Positive: for throat culture and antibiotics

Finally, patients usually experience swelling of the tonsils and lymph nodes in the neck, but swelling can also be located in the soft palate in the top of the mouth. The absence of tender anterior cervical lymph nodes, tonsillar enlargement, and tonsillar or pharyngeal exudates has been suggested as being the most useful finding in ruling out strep throat, with a negative likelihood of 0.74.[10]


Strep throat is caused by Group A streptococcal infection (GAS),[11] specifically the bacterium Streptococcus pyogenes.[12] It is spread by direct, close contact with an infected person.[13] It has been found that dried bacteria in dust are not infectious. Although moist bacteria on toothbrushes or similar items, which can persist for up to fifteen days,[14] might theoretically spread it, a decreased rate of recurrence in families following hygienic measures has not been shown rigorously.[11] Rarely, contaminated food, especially milk and milk products, can result in outbreaks.[15]

The incubation period for strep throat is thought to be between two to five days, but has been reported as long as eight days.[16][17]


Symptomatic therapies

Nonprescription over the counter drugs of ibuprofen and paracetamol (acetaminophen) both help relieve throat pain and reduce fever by an average of 2.2˚C or 2.3˚C in children.[18] Aspirin is not recommended for children due to the risk of Reye's syndrome. In adults aspirin, paracetamol, or ibuprofen help reduce back pain by 48% and sore throat by 31%.[19]


Antibiotics decrease the duration of symptoms (which last about 3–5 days[5]) by 1 or 2 days and reduce contagiousness. They are also prescribed out of a motivation to reduce rare complications such as acute rheumatic fever, acute glomerulonephritis (incidence of glumerulonephritis is not reduced by antibiotic therapy), and suppurative complications such as peritonsillar abscess.[20] The use of antibiotics should be balanced by the consideration of side-effects,[14] and it is reasonable to suggest no antimicrobial treatment in healthy adults who are averse to medication.[20] Antibiotics are prescribed for strep throat at a higher rate than would be expected from its prevalence.[21]

In one clinical trial, the greatest reduction in symptoms after antibiotic treatment occurred after 3 days. Out of all symptoms, reduction scores for muscle or joint pain was the most at 86%, and the lowest for sore throat at 67%.[22] Another clinical trial found that only (17%) of 42 children had positive throat cultures a day after antibiotic treatment.[23] Sometimes penicillin fails to completely treat the infection.[24]

Cephalosporins (such as cefazoline, cefuroxime, and ceftriaxone) are recommended for penicillin-allergic patients. In another study, 41 patients with confirmed penicillin allergy were evaluated with cefazoline, cefuroxime, and ceftriaxone—all cephalosporins—to see the allergic reaction. Skin tests with cephalosporins were clearly negative in 39 patients and all 41 patients tolerated the three cephalosporins administered.[25][26] Second-line antibiotics included amoxicillin,[27] clindamycin,[28] and oral cephalosporins which have a significantly better cure rate than penicillin.[29]

Studies have also shown that the broader-spectrum of antibiotics offer more effective short treatment courses than the traditional 10 days of Penicillin V,[30] but noted that "widespread use of broad-spectrum agents for a common infection is a significant concern in an age of increasing bacterial antibiotic resistance".[31] It is important to complete the full course of antibiotics to prevent rheumatic fever or an abscess on the tonsils. In one report of 500 patients, 30% had group A beta-hemolytic streptococcal pharyngitis, 0.2% had rheumatic fever and 0.2% had peritonsillar abscess (an abscess on the tonsils).[6]

Azithromycin and other macrolides have been used to treat strep throat in penicillin-allergic patients, however macrolide resistant strains of GAS are occasionally encountered. Approximately 5% of GAS isolates are macrolide resistant in the U.S., however local resistance rates may vary. In these strains, cross-resistance to macrolides, lincosamides, and streptogramins is possible. Some of the initial motivation for using antibiotics to treat all strep throat with antibiotics came from early studies showing that it reduced acute rheumatic fever at a military base, but it's difficult to generalize these findings to the current population.[32]


The symptoms of strep throat usually improve even without treatment in three to five days,[5] but without treatment the patient remains contagious for several weeks. Lack of treatment or incomplete treatment of strep throat can lead to various complications. Some of them may pose serious health risks. Therefore, streptococcal tonsillitis is important to recognize and treat early. There are also home remedies such as gargling salt water, lemon juice, in some cases mouthwash. The patient is considered to be contagious up to three days after being treated with antibiotics.[33]

List of complications arising from disseminated streptococcal infection (originating in the throat)[34]

See also


  1. ^ streptococcal pharyngitis at Dorland's Medical Dictionary
  2. ^ Xu J, Schwartz K, Monsur J, Northrup J, Neale AV (December 2004). "Patient-clinician agreement on signs and symptoms of 'strep throat': a MetroNet study". Fam Pract 21 (6): 599–604. doi:10.1093/fampra/cmh604. PMID 15528291. 
  3. ^ Know the Tell-Tale Signs of Strep,
  4. ^ Kids Health
  5. ^ a b c d e Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH (July 2002). "Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America". Clin. Infect. Dis. 35 (2): 113–25. doi:10.1086/340949. PMID 12087516. 
  6. ^ a b Ebell MH (2004). "Epstein-Barr virus infectious mononucleosis". Am Fam Physician 70 (7): 1279–87. PMID 15508538. 
  7. ^ Centor RM, Dalton HP, Campbell MS, Lynch MR, Watlington AT, Garner BK (1986). "Rapid diagnosis of streptococcal pharyngitis in adult emergency room patients". J Gen Intern Med 1 (4): 248–51. doi:10.1007/BF02596194. PMID 3534175. 
  8. ^ Komaroff AL, Pass TM, Aronson MD, et al. (1986). "The prediction of streptococcal pharyngitis in adults". J Gen Intern Med 1 (1): 1–7. doi:10.1007/BF02596317. PMID 3534166. 
  9. ^ McIsaac WJ, Goel V, To T, Low DE (2000). "The validity of a sore throat score in family practice". CMAJ 163 (7): 811–5. PMID 11033707. PMC 80502. 
  10. ^ Eaton CA (2001). "What clinical features are useful in diagnosing strep throat?". J Fam Pract 50 (3): 201. PMID 11252201. 
  11. ^ a b Falck G, Kjellander J, Schwan A (1998). "Recurrence rate of streptococcal pharyngitis related to hygienic measures". Scand J Prim Health Care 16 (1): 8–12. doi:10.1080/028134398750003331. PMID 9612872. 
  12. ^ Gieseker KE, Roe MH, MacKenzie T, Todd JK (2003). "Evaluating the American Academy of Pediatrics diagnostic standard for Streptococcus pyogenes pharyngitis: backup culture versus repeat rapid antigen testing". Pediatrics 111 (6 Pt 1): e666–70. doi:10.1542/peds.111.6.e666. PMID 12777583. 
  13. ^ Lindbaek M, Høiby EA, Lermark G, Steinsholt IM, Hjortdahl P (2004). "Predictors for spread of clinical group A streptococcal tonsillitis within the household". Scand J Prim Health Care 22 (4): 239–43. doi:10.1080/02813430410006729. PMID 15765640. 
  14. ^ a b Hayes CS, Williamson H (April 2001). "Management of Group A beta-hemolytic streptococcal pharyngitis". Am Fam Physician 63 (8): 1557–64. PMID 11327431. 
  15. ^ Asteberg I, Andersson Y, Dotevall L, et al. (2006). "A food-borne streptococcal sore throat outbreak in a small community". Scand. J. Infect. Dis. 38 (11-12): 988–94. doi:10.1080/00365540600868370. PMID 17148066. 
  16. ^ Sarvghad MR, Naderi HR, Naderi-Nassab M, et al. (2005). "An outbreak of food-borne group A Streptococcus (GAS) tonsillopharyngitis among residents of a dormitory". Scand. J. Infect. Dis. 37 (9): 647–50. doi:10.1080/00365540510044085. PMID 16126564. 
  17. ^ Coburn, A.F.; Pauli, R.H. (1941). "The interaction of host and bacterium in the development of communicability by Streptococcus haemolyticus". The Journal of Experimental Medicine 73 (4): 551–570. doi:10.1084/jem.73.4.551. PMID 19871096. 
  18. ^ Figueras Nadal C, García de Miguel MJ, Gómez Campderá A, Pou Fernández J, Alvarez Calatayud G, Sánchez Bayle M (2002). "Effectiveness and tolerability of ibuprofen-arginine versus paracetamol in children with fever of likely infectious origin". Acta Paediatr. 91 (4): 383–90. doi:10.1080/080352502317371607. PMID 12061352. 
  19. ^ Farhan, M., Leparc, J.M., Moore, N., Pelen, F., Vanganse, E., Verriere, F., & Wall, R. (August 1999). "The PAIN Study: Paracetamol, Aspirin and Ibuprofen New Tolerability Study: A Large-Scale, Randomised Clinical Trial Comparing the Tolerability of Aspirin, Ibuprofen and Paracetamol for Short-Term Analgesia". Clinical Drug Investigation 18 (2): 89–98. doi:10.2165/00044011-199918020-00001. Retrieved 2008-12-08. 
  20. ^ a b Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR (March 2001). "Principles of appropriate antibiotic use for acute pharyngitis in adults". Ann. Intern. Med. 134 (6): 506–8. PMID 11255529. 
  21. ^ Linder JA, Bates DW, Lee GM, Finkelstein JA (November 2005). "Antibiotic treatment of children with sore throat". JAMA 294 (18): 2315–22. doi:10.1001/jama.294.18.2315 (inactive 2009-11-10). PMID 16278359. 
  22. ^ Melbye H, Bjørkheim MK, Leinan T (2002). "Daily reduction in C-reactive protein values, symptoms, signs and temperature in group-A streptococcal pharyngitis treated with antibiotics". Scand. J. Clin. Lab. Invest. 62 (7): 521–5. doi:10.1080/003655102321004530. PMID 12512742. 
  23. ^ Snellman LW, Stang HJ, Stang JM, Johnson DR, Kaplan EL (1993). "Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy". Pediatrics 91 (6): 1166–70. PMID 8502522. 
  24. ^ Brandt CM, Allerberger F, Spellerberg B, Holland R, Lütticken R, Haase G (2001). "Characterization of consecutive Streptococcus pyogenes isolates from patients with pharyngitis and bacteriological treatment failure: special reference to prtF1 and sic / drs". J. Infect. Dis. 183 (4): 670–4. doi:10.1086/318542. PMID 11170997. 
  25. ^ Novalbos A, Sastre J, Cuesta J, et al. (2001). "Lack of allergic cross-reactivity to cephalosporins among patients allergic to penicillins". Clin. Exp. Allergy 31 (3): 438–43. doi:10.1046/j.1365-2222.2001.00992.x. PMID 11260156. 
  26. ^ Pichichero ME (2005). "A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing cephalosporin antibiotics for penicillin-allergic patients". Pediatrics 115 (4): 1048–57. doi:10.1542/peds.2004-1276. PMID 15805383. 
  27. ^ Feder HM, Gerber MA, Randolph MF, Stelmach PS, Kaplan EL (1999). "Once-daily therapy for streptococcal pharyngitis with amoxicillin". Pediatrics 103 (1): 47–51. doi:10.1542/peds.103.1.47. PMID 9917438. 
  28. ^ Martin JM, Green M, Barbadora KA, Wald ER (2004). "Group A streptococci among school-aged children: clinical characteristics and the carrier state". Pediatrics 114 (5): 1212–9. doi:10.1542/peds.2004-0133. PMID 15520098. 
  29. ^ Casey JR, Pichichero ME (2004). "Meta-analysis of cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis in children". Pediatrics 113 (4): 866–82. doi:10.1542/peds.113.4.866. PMID 15060239. 
  30. ^ Adam D, Scholz H, Helmerking M (2000). "Short-course antibiotic treatment of 4782 culture-proven cases of group A streptococcal tonsillopharyngitis and incidence of poststreptococcal sequelae". J. Infect. Dis. 182 (2): 509–16. doi:10.1086/315709. PMID 10915082. 
  31. ^ Lord RW (2000). "Is a 5-day course of antibiotics as effective as a 10-day course for the treatment of streptococcal pharyngitis and the prevention of poststreptococcal sequelae?". J Fam Pract 49 (12): 1147. PMID 11132064. 
  32. ^ David H. Newman (2008). Hippocrates' Shadow. Scribner (2008). p. 110–16. ISBN 1-4165-5153-0.,M1. 
  33. ^ Mitchell, Richard Sheppard; Kumar, Vinay; Abbas, Abul K.; Fausto, Nelson (2007). Robbins Basic Pathology: With STUDENT CONSULT Online Access. Philadelphia: Saunders. pp. 537. ISBN 1-4160-2973-7. 
  34. ^ UpToDate Inc

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