Now, let's talk about strep throat.
It's also called streptococcal pharyngitis.
This accounts for a small
percentage of sore throats.
It's a bacterial infection.
This is transmitted by direct contact with mucous
or sores of someone else with a strep bacteria.
This can be via kissing, droplets, sharing
water bottles and utensils or from fomites
which are inanimate objects that
are covered in the strep bacteria.
This is caused by strep pyogenes which is
a Group A beta-hemolytic strep or GABHS.
and this is a gram-positive cocci
that is present in chains.
The strep bacteria is going to adhere to
the specific receptors on the host cells
and the bacteria will adhere to the
pharyngeal and dermal epithelial cells.
Then, it will start to invade the host tissues.
The bacteria will start to release these pyogenic
exotoxins and that will cause your patient to fever.
Signs and symptoms of strep
throat usually include:
a sore throat that starts pretty rapidly.
Healthy patients come in and they'll say, "I felt
fine yesterday and now I can barely swallow."
They'll have the pain when they swallow
and usually a fever is present
unless they're on antipyretics or
medications to decrease their fever.
They will have red and swollen tonsils
sometimes with white patches and streaks
and this is called exudative tonsils.
They may have tiny red spots on the roof
of their mouth and these are palatal petechiae.
The lymph nodes in the neck in the front
may be swollen at the tonsillar level
and the anterior cervical lymph node chain.
And when patients come in, they wanna
know, do they have strep throat?
and so you have to discern,
could they maybe have a virus?
Signs and symptoms of strep
usually do not include a cough,
and a cough is usually present
when your patient has a cold.
Strep doesn't usually have a runny nose but patients
with a cold usually will have a runny nose.
Strep doesn't usually cause
hoarseness or laryngitis.
This is also usually present
with viral illnesses like colds.
And conjunctivitis is usually not present
when a patient has strep throat.
Now let's look in.
On exam, your patient will open their
mouth and often, you'll use your light
to took at the back of the throat.
You're looking for a
The first is the soft palate,
it's going to look red.
The uvula may be
red and enlarged.
You're gonna be looking at the tonsils and remember
you're gonna be grading those according to size.
There may be these tiny, red, pinpoint
hemorrhages on the soft palate
and the patient may have the white
or yellow patches on their tonsils.
These are all of the classic signs
and symptoms of strep throat.
Remember, you're looking for throat
redness, pus or exudate on the tonsils,
anterior cervical or tonsillar
lymph node adenopathy,
palatal petechiae which are the
small, pinpoint hemorrhages.
Your patient will have a fever
unless they're on antipyretics.
Abdominal pain, now this seems like an atypical symptom
of strep throat but let's talk about this a little bit.
So strep throat makes the lymph nodes
swell in the neck, we know this.
But it also makes the lymph nodes in the abdomen
swell and these are the mesenteric lymph nodes.
Often in kids under 5 who present with
abdominal pain for no other cause,
we will run a strep test because this can be
due to the swollen lymph nodes in the abdomen.
Your patient can have a fine, raised rash
on the trunk and this is the scarlatina rash.
Remember, your patient with strep
throat typically does not have a cough.
If your patient has a cough, they
usually have a viral illness.
Now when the patient presents with a sore throat, the
clinician needs to decide if the patient needs a strep test.
We don't test every patient who presents
to the clinic with a sore throat.
They way to do this is with a diagnostic criteria called
either the Centor criteria or the McIsaac criteria.
Here's an example.
You score the points based
on the patient's symptoms.
They get a point if
they have a fever.
The patient will get another point
if they have absence of cough.
The patient will get another point
if they have tender lymphadenopathy
in either their tonsillar or
anterior cervical chains.
They will earn another point if they
have tonsillar swelling or exudates.
So the maximum for
this is 4 points.
That's the Centor criteria.
Next, you can adjust this based on the patient's
age and this is the McIsaac criteria.
So we know that strep is most prevalent in the 3 to
14-year old population, so kids will gain another point.
If your patient is 15 to 44 years old,
they won't add or subtract any points
and strep is less common in the older adult population,
so if your patient is older that 45 years,
you will actually subtract
a point in their score.
Next, the clinician will total the points.
If the patient scores 0 to 1 point, it's unlikely
to be strep pharyngitis causing their symptoms.
It could be from a virus or a cold and no further
testing or antibiotic treatment is recommended.
If the patient scores 2 to 3 points, it is recommended to
do a rapid antigen test and this is a rapid strep test.
You can also do a follow
up throat culture.
Now in these patients, we would only treat if the rapid
strep test is positive or the throat culture is positive.
If your patient receives 4+ points, meaning they have every
single sign of strep throat, and/or adjusted for age,
they only have a 52% chance
of having a strep throat.
The other 48% of the time,
it's going to be viral.
So these patients, you can treat emperically
while you wait on their results
but this is a discussion
to have with your patients
because that's not without risk.
Here you can see a
positive test result.
This can be a dark positive line in addition
to the control line or a faint positive line.
With strep testing, any line
is considered positive.
Here you'll find a negative.
This means there's only
the control line present.
This is an invalid test.
This means the control line didn't show up as it should and
this patient should either be re-swabbed or re-tested.
So how do you manage
Well, strep throats typically are gonna away in 3
to 7 days with or without antibiotic treatment.
Although, if strep throat is not treated with antibiotics,
the patient can remain contagious for 2 to 3 weeks
and there's a higher risk for
complications such as rheumatic fever.
Remember, your patient would be contagious with strep
throat until they're on antibiotics for 24 hours.
So they need to stay out of school,
work and community activities.
Patients with strep throat should be treated with an
antibiotic that is likely to eradicate the organism
and they're typically on
10 days of treatment.
Penicillin or amoxicillin are commonly
recommended because they're effective,
they have few adverse effects
and they're affordable.
It's important to remind the patient to complete
the treatment and not save any extra antibiotics.
Patients can also treat their symptoms
with acetaminophen or ibuprofen
and this can help them manage
their pain and their fever.
and warm salt water gargles are also a great
option for controlling their throat pain.