The Child with Sore Throat

1. The Child with Sore Throat Bassam Y. Abu-Libdeh, MD Makassed Hospital & Al-Quds University Ramallah Conference April 2011

3. Objective • Rational approach to sore throat in practice. • Judicious use of antibiotics in sore throat.

4. Introduction • Sore throat is any painful sensation localized to the pharynx or surrounding anatomy. • Ability of young children to identify and define their symptoms varies. • Sore throat can be the symptom of a disease process that does not directly affect the pharynx. • URTIs :- substantial portion of visits to pediatricians. • Approximately ⅓ of URTIS feature a sore throat as the primary symptom.

5. Life Threatening conditions Epiglottitis Retropharyngeal abscess. Lateral pharyngeal abscess. Peritonsillar abscess. IM. Diphtheria Lemierre's syndrome Common conditions Viral Pharyngitis (70%) Strep Pharyngitis (20-30%) Infectious Mononucleosis Others. Causes of Sore Throat Infection is the most common cause of sore throat and the etiologic agents are usually respiratory viruses. Tonsillitis=pharyngitis=tonsillopharyngitis

6. Sore Throat : common conditions Viral (70%) • RHINOVIRUS 40% • CORONAVIRUS 10 -20% • ADENOVIRUS 10% • HERPES VIRUS 8% • PARAINFLUENZA VIRUS INFLUENZA VIRUS COXSACKIE VIRUS EBSTEIN BARR VIRUS <2% • CYTOMEGALOVIRUS <2% • HIV <1%

7. Sore Throat : common conditions Bacterial (20-30%) • β hemolytic streptococcus group A (BHSA) 75 - 90% • β hemolytic streptococcus group C (BHSC) 5-10 % • Others :- Arcanobacterium haemolyticum, Francisella tularensis, Mycoplasma pneumoniae, Neisseria gonorrhoeae, and Corynebacterium diphtheriae • Haemophilus influenzae and Streptococcus pneumoniae, may be cultured from the throats of children with pharyngitis, but their role in causing pharyngitis has not been established.

9. Bacterial Vs Viral Sore ThroatNO ABSOLUTE DEMARCATION CLINICALLY

11. Clinical Scoring System I suggest the acronym FLENCA

12. Lab Diagnosis RAPID STREP TEST • SENSITIVITY : 61 – 95 % SPECIFICITY : 88 – 100 % • CONSUMES : 10 MINUTES • EASY TO PERFORM. • INCREASES NUMBER OF PATIENTS APPROPRIATELY TREATED FOR STREPTOCOCCAL INFECTION. • DECREASES MORBIDITY. • Negative strep test to be confirmed by conventional culture .

13. Lab Diagnosis • CBC : POLYMORPHONUCLEAR LEUCOCYTOSIS. • THROAT CULTURE * SENSITIVITY 90 – 95 % * SPECIFICITY 99 % * GOLD STANDERD * CONSUME 24 – 48 HOURS * INDICATIONS :- a. Pharyngitis without hoarseness or significant cough, especially with fever b. Febrile cervical adenitis c. Symptomatic family contacts of patients with streptococcal pharyngitis. * NEGATIVE CUITURE DOES NOT RULE OUT DIAGNOSIS

14. The ideal approach Child with sore throat Rapid Antigen Test (Quick test) Positive Negative Throat culture Treat as bacterial pharyngitis Positive Negative Viral pharyngitis

15. The practical Approach Child with sore throat • Number of signs and • Symptoms present:- • Lack of cough • H/O fever • Tonsillar Exudates • Swollen, tender anterior cervical LN 2 or 3 present All 4 present None or 1 present QT Symptomatic Rx; Consider other causes -Ve +ve Throat Cx Treat with antibiotics -ve +ve

16. Management SYMTOMATIC:- • GENERAL MEASURES:- * ADEQUATE FLUIDS. * WARM GARGLES:- salt & water. * SOOTHING (USE HONEY & LEMON):- HONEY COATS AND SOOTHES THROAT. LEMON HELPS MUCOSAL HEALING. • THROAT LOZENGE OR HARD CANDY : STIMULATES SALIVA PRODUCTION WHICH BATHES & CLEANES THROAT. • SIMPLE ANALGESICS / ANTIPYRETICS • STERIODS ??? DEXAMETHASONE : RAPID ONSET & GREATER DEGREE PAIN RELIEF ANTIBIOTICS:- See the following algorithm.

17. Child with positive RST (QT) or positive throat Culture. No Penicillin Allergy Allergic to Penicillin FIRST LINE Penicillin V or Amoxicillin x 10 days < 27 kg:- 250 mg bid ≥27 kg:- 500 mg bid FIRST LINE Erythromycin ethyl succinate :- 40 mg/kg/day bid X 10 days Azithromycin 12 mg/kg/day Once daily for 5 days SECOND LINE Cephalexin 40 mg/kg/d bid x 10 d Cefadroxil 30 mg/kg OD x 10 d Amoxicillin-Clavulanate 40 mg/kg/d bid X10 d • May use 2nd and 3rd line antibiotics • as patients without Penicillin • Allergy conditioned:- • No penicillin used in the product. • Use cephalosporins if no h/o immediate • Hypersensitivity to penicillin. THIRD LINE Clindamycin 7 mg/kg/dose tid x 10 d Penicillin and Rifampin (10-20 mg/kg/d od or bid) Others:-Cefuroxime 20 mg/kg/d bid x 10 d Cefdinir 14 mg/kg/d bid x 5 days Ceftriaxone 50 mg/kg/d OD x 3 days

18. Antibiotic Rx for βHSA • DOSAGE & DURATION TO ERADICATE ORGANISM FROM PHARYNX • BENEFITS OF ANTBIOTIC Rx:- a. PREVENTION OF ACUTE RHEUMATIC FEVER b. PREVENTION OF SUPPURATIVE COMPLICATIONS c. IMROVEMENT OF CLINICAL SYMPTOMS AND SIGNS d. REDUCTION IN TRANSMISION OF βHSA TO CLOSE CONTACTS

19. Recurrent Pharyngitis/treatment failure • Non adherence to antibiotic regimen. • Presence of beta-lactamase-producing anaerobic bacteria. • Penicillin-tolerant Group A streptococci. • Presence of penicillin-resistant staphylococci. • Re infection with the same serotype from the patient's toothbrush.

20. Management of recurrences • Make sure that recurrences are truly streptococcal infections, not carrier. • Confirm that recurrences are caused by Group A streptococci. • On the second or third clinical recurrence, use clindamycin. • Give the patient with multiple recurrences a prophylaxis regimen similar to that used for prevention of acute rheumatic fever for approximately 3 months. • Consider a tonsillectomy for selected patients who have recurrent streptococcal pharyngitis • Change toothbrush.

22. Complications of bacterial pharyngitis Suppurative Non Suppurative Peritonsillar abscess Retropharyngeal abscess • Acute Rheumatic Fever • 3 wks • 1% of all strep throat • 9 days of delayed Rx acceptable • 2. Post Strep GN • 3. Post Strep Reactive arthritis (PSRA) • 4. pediatric autoimmune neuropsychiatric • disorders associated with streptococcal • infections (PANDAS).

23. Prevention • HAND HYGIENE : ALCOHOL BASED HAND SANITIZER OR SOAP AND WATER. • AVOID SHARING EATING UTENSILS, FOOD,GLASSES, NAPKINS OR TOWELS • AVOID TOUCHING PUBLIC PHONES OR DRINKING FOUNTAINS WITH MOUTH • REGULARLY CLEAN TELEPHONES, T.V. REMOTE, COMPUTER KEY BOARD WITH SANITIZING CLEANSER. • AVOID ACTIVE & PASSIVE SMOKING. • HUMIDIFY YOUR HOME. • COUGH OR SNNEZE IN TISSUE & DISPOSE. • ON COMMERCIAL PLANE KEEP AIR NOZZLE CLOSED.

24. Prevention • Multivalent streptococcal vaccines based on M protein peptides are under development. • Antimicrobial prophylaxis with daily oral penicillin prevents recurrent GABHS infections but is recommended only to prevent recurrences of acute rheumatic fever.

25. Conclusions • Most cases of sore throat are caused by viruses and there is no need for antibiotic treatment • Don't culture anyone you wouldn't treat if the culture were positive. • A throat culture is a laboratory guide, not a decision maker. • Don't look for asymptomatic carriers unless rheumatic fever is involved. • Don't culture for bacteria other than βHSA (usually).

26. We treat strep pharyngitis mainly to prevent ARF. • Don't treat streptococcal pharyngitis with broad-spectrum antibiotics. βHSA is universally sensitive to penicillin. • Don't bother with follow-up cultures unless adherence with oral medication is doubted. • Don't get ASO titers unless acute rheumatic fever is suspected. • Don't bother with CRP, streptozyme, or WBC and differential.