Strep Pharyngitis / Acute Pharyngitis / Strep throat

History & Physical.
Differential diagnosis.
Red flags:
-s/sx of epiglottitis: Acute onset of dysphagia, odynophagia, drooling, high fever, anxiety, and muffled voice;
-s/sx of peritonsillar abscess: fever, sore throat, dysphagia, trismus, a muffled voice (“hot potato” voice), malaise, Odynophagia / severe unilateral pain, Otalgia (ipsilateral), severe sore throat, worse on one side, drooling, cervical lymphadenitis, red, swollen soft palate with uvula deviation to contralateral side and enlarged tonsil; foul-smelling breath (fetor); sometimes large tonsillar swelling.
-s/sx of retropharyngeal abscess: inability to swallow, worsening of sx after several days, bulging of the retropharyngeal wall.
-s/sx of diphtheria: pseudomembrane, cervical lymphadenopathy,
-s/sx of submandibular space infections (Ludwig’s angina)
-s/sx of a retromolar abscess and neoplasm (lymphoma or carcinoma)
-swelling of the mandible.
-toxic looking patient.
CENTor Criteria:
If EBV (infectious mono) suspected, get Heterophile Antibodies (note 25% false in 1st wk); CBC (Lymphocytosis with >10% atypical lymphocytes, mild decrease in platelets and increase in LFTs)

Treatment
Outpatient tx vs. ED treatment?
-Send to ED if s/sx concerning for any of the red flag disease conditions above.
-Outpatient Antibiotic Choices for GAS (Weight based for kids; fixed doses for adults) for Group A Strep.
-Abx in GAS given to prevent rheumatic heart dz, prevent abscess development, and reduce symptoms.
-Will consider Dexamethasone 10 mg x 1 for adult patients who don’t meet criteria for abx treatment.
-Tylenol, NSAIDs, fluids, gargling w/ warm salt water, lozenges, humidifier.
-Tx cause upon diagnosis.
-RTC or go to urgent care/ED if s/sx don’t improve after 3-4 d of antibiotics. If pt doesn’t improve, will reconsider dx or evaluate for complications.
-If repeat abx needed, will give Augmentin (Amox-Clav) or 1st gen Cephalosporin.

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Key Points

• Dexamethasone 10 mg x 1 dose (single dose) should be considered for patients in whom antibiotics are not indicated. Research shows significant symptom resolution at 48 hours compared to placebo. (AFP 2017)
• “For adults, simply use the CENTor criteria without the age criteria. For kids, use the Modified Centor criteria with age included. The number of Centor criteria present correlates with the likelihood of acute GAS pharyngitis in an adult patient.
• Most patients with two or fewer Centor criteria should not receive either antibiotic treatment or diagnostic testing. Exceptions might include patients with a history of rheumatic fever, or those at highest risk for severe infections.
• For adults with three or more Centor criteria, we get a sensitive RADT without reflex throat culture for negative results. However, the use of backup culture can also be considered a reasonable approach in patients with Centor score ≥3 with negative RADT but in whom clinical suspicion for GAS remains high.
• For adults at higher risk for severe infections (eg, poorly controlled DM, immunocompromised, on chronic corticosteroids), throat culture can be obtained at the initial visit even if the rapid antigen detection test is negative for GAS.
• Patients in whom pharyngitis secondary to GAS has been determined are treated with antibiotics.
• Adults who do not have GAS should be offered symptomatic treatment”

Reference

https://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

Am Fam Physician. 2018 May 1;97(9):575-580. Croup: Diagnosis and Management