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Strep throat

Strep throat (or "Streptococcal pharyngitis", or "Streptococcal sore throat") is a form of Group A streptococcal infection that affects the pharynx. more...

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Medicines

Symptoms

The signs and symptoms of strep throat are red, sore throat with white patches on tonsils, swollen lymph nodes in neck, fever, and headache. Nausea, vomiting, and abdominal pain are more common in children. The patient will usually not have a cough, unlike in a viral infection or coldlike symptoms including stuffy noses and sneezing.

Transmission

The illness is caused by the bacterium Streptococcus pyogenes and is spread by direct, close contact with patients via respiratory droplets (coughing or sneezing). Casual contact rarely results in transmission. Rarely, contaminated food, especially milk and milk products, can result in outbreaks. Untreated patients are most infectious for 2-3 weeks after onset of infection. Incubation period, the period after exposure and before symptoms show up, is 2-4 days. Patient is no longer infectious within 24 hours of commencing treatment.

Diagnosis

The throat of the patient is swabbed for culture or for a rapid strep test (5 to 10 min) which can be done in the doctor's office. A rapid test tests for the presence of typical bacterial antigens in the swab, which are detected by specific antibodies provided in the kit. If the rapid test is negative (=normal), a follow-up culture (which takes 24 to 48 h) may be performed. A negative culture suggests a viral infection, in which case antibiotic treatment should be withheld or discontinued.

In the UK, rapid strep testing is not available to general practitioners and a clinical decision must be made whether to treat, whilst awaiting upto 7 days for a swab result to be reported. This is criticized for encouraging overuse of antibiotics (see antibiotic resistance).

Treatment

Antibiotic treatment will reduce symptoms slightly, minimize transmission, and reduce the likelihood of complications. Treatment consists of penicillin (orally for 10 days; or a single intramuscular injection of penicillin G). Erythromycin is recommended for penicillin-allergic patients. Second-line antibiotics include amoxicillin, clindamycin, and oral cephalosporins. Although symptoms subside within 4 days even without treatment, it is very important to start treatment within 10 days of onset of symptoms, and to complete the full course of antibiotics to prevent rheumatic fever, a rare but serious complication.

Amoxicillin should be avoided for treatment of a sore throat if bacterial (swab) confirmation has not been obtained since it causes a distinctive rash if the true illness proves to be glandular fever, better known as mononucleosis. This rash is harmless but alarming.

Read more at Wikipedia.org


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Cephalosporins vs. penicillin for treatment of strep throat
From American Family Physician, 3/15/05 by Bill Zepf

Penicillin has long been the favored antibiotic for the treatment of pharyngitis caused by group A streptococci, but some recent studies have raised concerns about possibly increasing failure rates with penicillin therapy. Two previously published meta-analyses comparing cephalosporins with penicillin suggest that cephalosporins are more likely to achieve eradication of streptococcal pharyngitis infection. Casey and Pichichero present another meta-analysis of cephalosporins and penicillin; this analysis included adult patients with strep throat.

The authors employed rigorous statistical standards to decide which studies merited inclusion in the meta-analysis to avoid some of the criticisms leveled at prior meta-analyses. Of the 66 published reports initially reviewed, only eight (including nine trials) were included in the final data analysis. All of the included studies had been performed within the past 25 years, and a variety of first-, second-, and third-generation cephalosporins were used among the different trials. A total of 2,113 adult patients from the nine trials were pooled for data analysis.

The primary outcome measured was the rate of bacteriologic cure, i.e., a negative streptococcal culture after antibiotic therapy. To sum up all the trial results, bacteriologic cure was about twice as likely (odds ratio, 1.83) with a cephalosporin than with penicillin. Point estimates in seven of the studies favored cephalosporins; four of these showed a statistically significant benefit. Two studies had a nonsignificant trend favoring penicillin.

Clinical cure, i.e., resolution of pharyngitis symptoms, also was about twice as likely with cephalosporins (odds ratio, 2.29) than with penicillin. When the authors restricted the meta-analysis to trials that passed higher quality standards (for example, double blinding and elimination of chronic streptococci carriers or test-of-cure throat cultures), the odds ratios were somewhat lower but still favored cephalosporins.

The authors conclude that bacteriologic and clinical cure of streptococcal pharyngitis is about twice as likely to occur with cephalosporin therapy than with penicillin.

Casey JR, Pichichero ME. Meta-analysis of cephalosporins versus penicillin for treatment of group A streptococcal tonsillopharyngitis in adults. Clin Infect Dis June 1, 2004;38:1526-34.

EDITOR 'S NOTE: Although the authors have gone to considerable lengths to provide a "clean " and reliable meta-analysis, their published results are missing vital data. Reporting only odds ratios provides a relative comparison of cephalosporins and penicillin, but the absolute numbers relating to cure rates and other outcome measures also are needed so that the clinical significance of any differences can be assessed. For example, if the failure rate with a cephalosporin was 2 percent while the failure rate of penicillin was 4 percent, it could be said that treatment failure was twice as common with penicillin, and perhaps it could then be inferred that penicillin should not be used. If the absolute numbers are reviewed, however, the clinical significance of a 96 percent or a 98 percent success rate would be much more debatable.

In the meta-analysis reviewed here, some individual trials favored cephalospori ns while others favored penicillin, leading one to suspect that, overall, these antibiotics had largely similar effects. An accompanying editorial (1) questions the importance of the 5.4 percent absolute difference in eradication rates from the pooled studies, concluding, for this and other reasons, that "penicillin at this time remains the drug of choice."--B.Z.

REFERENCE

(1.) Bisno AL. Are cephalosporins superior to penicillin for treatment of acute streptococcal pharyngitis? [Editorial] Clin Infect Dis 2004;38:1535-7.

COPYRIGHT 2005 American Academy of Family Physicians
COPYRIGHT 2005 Gale Group

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