Assessment

Fever - Absent or low grade Fever - low to moderate grade

Exudate - Absent or minimal Exudate - small to large amounts

Tonsillar enlargement & Tonsillar enlargement &

erythema - minimal erythema - moderate to severe

Associated findings - Associated findings -

Nasal congestion Palatal petechiae

Rhinorrhea Cervical lymphadenopathy

Post-nasal discharge Nausea/vomiting/anorexia

Abdominal pain

GABHS exposure

Viral URI Throat Culture_{1, 2}

Symptomatic tx - Positive Negative

Fluids , Rest, Acetaminophen

Antibiotic tx₃ Supportive tx

Isolate from school

X 24hrs

F/U 7-10d

Symptoms persist Symptoms resolve

Heterophile Antibody Test

or Monospot test

Repeat Culture₄

Positive Heterophile Negative Culture Positive Culture

or Monospot

Infectious Mononucleosus Culture for GC if Repeat tx₅ child abuse suspected

or sexually active

1. The differentiation of viral and GABHS pharyngitis is often difficult. Therefore, throat cultures are obtained on all children who present with exudative pharyngitis. The accuracy of rapid streptococcal tests is dependent on the quality of the throat culture and number of streptoccal organisms present. A positive rapid strep test is considered diagnostic of GABHS. However because false negative tests occur in 20-40% of rapid strep tests, a negative test report should be followed by a traditional throat culture.

2. Treatment with Penicillin within the first 9 days of illness prevents rheumatic fever. Therefore, for children seen early (within the first 7 days of symptom onset) in the disease treatment may be delayed until the results of the throat culture are known.

3. Penicillin V is the drug of choice for the treatment of GABHS, except in penicillin allergic children. The dosage is 25-50mg/kg/d; tid X 10days. Amoxicillin has been used by some health providers as an alternate to Penicillin V, but is not recommended as rashes may develop in children with Epstein Barr virus. Benzathine penicillin G 600,000U for children weighing <27Kg; 1,200,000U for children weighing >27kg intramuscularly X 1 may be considered for children in whom parental compliance is questioned. Erythromycin, 20-40mg/kg/d tid X 10d, may be substituted in children with penicillin allergy.

4. Post-treatment throat cultures are indicated in patients who are high risk for rheumatic fever (RF) or who continue to be symptomatic.

5. Repeat courses of antibiotics are not indicated for asymptomatic children who continue to harbor GABHS unless at risk for RF. If symptomatic, repeat antibiotic courses are necessary. Benzathine penicillin G IM X 1 is the preferred treatment option. Alternate antibiotic choices include amoxicillin clavulanate, dicloxacillin, clindamycin, and Penicillin + Rifampin.

Reference:

Peters, G. (Ed.) (1994). 1994 Red Book, Report of Committee on Infectious Disease, 23rd Ed. Elk Grove Village, IL: American Academy of Pediatrics, pp 434-436.