March 2004

I was on the WB 11 Morning News on February 27th doing the weather forecast. My 2 minutes of fame! How did I do? I’m not quite ready to give up my day job yet but Hurricane Howie has a nice ring to it!

Dr. Barenfeld

Strep Throat--------------------------------------------

A sore throat is one of the most common symptoms of illness seen in Pediatrics. Its causes and treatment options are a source of great confusion for parents. Hopefully, I can answer most of the questions I have been asked over the years.

What causes a sore throat? Many different germs can cause a sore throat. Strep throat as a cause is only responsible for about 15-20% of cases. Only strep throat needs to be treated with antibiotics. Other causes of sore throat primarily involve viruses which do not respond to antibiotics and resolve without treatment. Throat lozenges and cough and cold medications will help alleviate a sore throat. One severe form of sore throat seen mainly in adolescents is mononucleosis. The treatment for mono does not involve antibiotics either.

So how can we tell which sore throats are due to strep? As I always say, not all children read the medical texts and therefore present to us in ways not generally described in the medical literature. This can make the diagnosis on examination alone, quite difficult. Typically, strep throat occurs in children between the ages of 5 and 15, is rare in children younger than 2 years and is most commonly seen in winter and early spring. A history of close contact (i.e. sibling, classmate) or a community epidemic makes strep throat more likely. Patients with strep throat commonly present with the sudden onset of sore throat and fever. Headache, nausea and vomiting may also be present. Cough, congestion, diarrhea and pink eye usually point to non-strep throat causes of sore throat. On examination we find swollen and red tonsils and sometimes pus on the tonsils. Tender enlarged glands in the neck are common. Sometimes we see a red swollen tongue that classically has the moniker “strawberry tongue”. Scarlet fever is simply strep throat with a rash. The rash of scarlet fever classically feels rough to the touch like sandpaper.

What tests can be done? So as not to treat everyone with a sore throat with antibiotics, a throat culture should be done. Unfortunately, many children find this procedure more difficult than getting a shot. Occasionally, a child with the classic symptoms of strep throat will be spared a throat culture and given antibiotics but this is not the general rule. Most experts feel the overnight throat culture is more accurate than the Rapid Strep Test (RST). I usually reserve the RST for families going away on vacation or having some other reason for needing to know the result right away. Our office policy is to do the overnight throat culture and start antibiotics pending the results of the culture the following day. This enables children to get back to school or work sooner since strep throat is no longer contagious after 24 hours on antibiotics. If the throat culture is negative we simply stop the antibiotic.

Which antibiotic is best for the treatment of strep throat? Penicillin is still the recommended first-line treatment. There have been some reports of increased resistance to penicillin but this is still uncommon. However, penicillin has a poor taste and must be given 3 times per day so we often use amoxicillin or another antibiotic instead. Re-culturing a patient after treatment of strep throat who has improved is not necessary.

What does it mean to be a carrier of strep? Strep carriers are people who harbor the strep organism in their throat. The strep just lives there but does not cause any evidence of infection. To help you better understand, if we took a culture of your skin, it would show many organisms. The organisms are just using you as a rest stop and not causing you any harm. Only under certain circumstances will one of these germs actually cause an infection of the skin. During strep season as many as 20% of school age children may be strep carriers. Let’s now say that your child gets a cold with a sore throat. You bring your child into the office and we do a throat culture. The next day you get a call from our office telling you that the culture was positive for strep and that your child needs a course of antibiotics. If your child is a strep carrier the strep germ will be cultured from the throat but it is actually the cold virus causing your child’s infection. This is important because strep carriers do not require antibiotics. So in this scenario your child will be treated unnecessarily with antibiotics and the cold symptoms will just go away on their own. The only way to suspect someone as being a strep carrier is if we see repeated “strep throat” in a child over a short period of time without having any negative throat cultures in between. Remember only about 15-20% of sore throats are due to strep. In this scenario we would re-culture your child after he/she finishes the antibiotic and has no sore throat. If the culture is positive, then your child would be a strep carrier, if negative then the infection was due to strep. So, now what do we do with strep carriers? Well, nothing really. We can try giving special antibiotics to try to eliminate the carrier state but this has only limited benefit. Strep carriers don’t require antibiotics, are not sick and also don’t usually transmit the strep to others. We just need to be more careful before giving this child antibiotics for each sore throat.

What is the role of tonsillectomy? Tonsillectomy was at one time the most common surgical procedure in the U.S. However, there are risks to any surgical procedure and although tonsillectomy will decrease the incidence of strep throat, it won’t eliminate it completely. Today, the vast majority of children are treated with multiple courses of antibiotics before being considered for tonsillectomy.