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Streptococcal pharyngitis
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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
DR.T.V.RAO MD 9
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
DR.T.V.RAO MD 10
• 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
DR.T.V.RAO MD 11
PROGRESS OF EVENTS IN GROUP A STREPTOCOCCAL INFECTION
DR.T.V.RAO MD 12
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
DR.T.V.RAO MD 13
DIAGNOSIS
DR.T.V.RAO MD 14
COLLECTING A APPROPRIATE SPECIMEN IS HIGHLY ESSENTIAL
DR.T.V.RAO MD 15
• 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
DR.T.V.RAO MD 16
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
DR.T.V.RAO MD 17
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. [
DR.T.V.RAO MD 18
OBSERVATION OF STREPTOCOCCUS GROUP A ON SHEEP BLOOD AGAR PLATES
DR.T.V.RAO MD 19
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.
DR.T.V.RAO MD 20
• 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
DR.T.V.RAO MD 21
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
DR.T.V.RAO MD 22
• Otitis media
• Sinusitis
• Peritonsillar abscess (quinsy)
• Suppurative cervical adenopathy
• Rheumatic fever
• Post streptococcal glomerulonephritis
COMPLICATIONS OF STREPTOCOCCAL INFECTION
DR.T.V.RAO MD 23
• Complications arising from streptococcal throat infections include:
• Acute rheumatic fever
• Scarlet fever
• Streptococcal toxic shock syndrome]
• Glomerulonephritis]
• PANDAS syndrome]
COMPLICATION OF STREPTOCOCCAL INFECTIONS
DR.T.V.RAO MD 24
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.
DR.T.V.RAO MD 25
STREPTOCOCCAL GROUP A INFECTIONS CAN PRODUCE RHEUMATIC HEAR DISEASE AND
GLUMORELONEPHRITS
DR.T.V.RAO MD 26
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.
DR.T.V.RAO MD 27
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.
DR.T.V.RAO MD 29
FOLLOW ME FOR MORE ARTICLES OF INTEREST ON ISSUES OF INFECTIONS
DR.T.V.RAO MD 30
• Programme created by Dr.T.V.Rao MD for Medical and Paramedical students in the
developing World