Rapid Strep Research Articles

A Case of Necrotising Pneumonia in the Setting of Influenza Infection

A 37 year old male with past medical history of HIV (unknown CD4+ count and viral load, on HAART with questionable compliance), IV drug abuse, presented to ER with complaints of three day cough productive of yellow/ brownish sputum, subjective fevers, chills, chest pain aggravated by coughing and deep breaths, diarrhea, vomiting. He reported being in contact with people who had flu. Vitals showed temperature of 38.3 Celsius, respirations 22/ min, heart rate of 114/min, O2 saturation of 97% which rapidly decompensated to 85% on room air. On physical exam patient was in moderate to acute distress, with rhonchi in bilateral lung fields, tachypneic, tachycardic, occasionally producing blood tinged sputum. Labs showed severe neutropenia with bands, normal hemoglobin and hematocrit, elevated lactate, and anion gap metabolic acidosis. Influenza A test was positive. Blood cultures did not show any growth, and rapid strep test was negative. Gram staining was used to identify bacterial morphology. Repeated arterial blood gas analysis showed increasing A-a gradient with progressively worsening PO2:FiO2 ratio. Chest X-ray showed infiltrates in right upper and left middle lung. He was treated for sepsis secondary to pneumonia with intravenous fluids, azithromycin and ceftriaxone (switched to vancomycin and cefepime) neupogen. Patient went into severe sepsis and septic shock, was intubated and started on vasopressors. He subsequently developed massive hemoptysis with expectoration of approximately 3 liters of blood. Patient expired after 45 minutes of resuscitation, 19 hours after admission.

Acute Herpes Esophagitis in an Immunocompetent Adolescent Female

Purpose: Herpes esophagitis is well-described in organ transplant and HIV-positive patients, but is rare in immunocompetent hosts. Immunocompromised patients can have severe herpes infections involving the CNS, skin, lungs, and gastrointestinal tract, while healthy patients typically present with only mild oral lesions. The few previously described cases of herpes esophagitis in immunocompetent patients have affected primarily adult males. This is a case of severe herpes esophagitis in a young healthy female. An 18-year-old Caucasian female presented to the emergency department with sudden-onset, severe (9/10) mid-anterior chest pain. She complained of three days of fever, sore throat, and odynophagia to the point of dehydration. She was a healthy high school senior with no drug or alcohol use. On physical exam, she was anxious and in distress with a temperature of 39.2°C. Palpable cervical lymphadenopathy and an erythematous oropharynx were noted. Heart and lung examinations were normal. Laboratory tests revealed a normal CBC, Chem-7, and d-dimer. Pregnancy test and rapid strep test were negative. Electrocardiogram showed only sinus tachycardia. She was discharged from the ED with empiric antibiotics and a PPI. Later that evening, she returned with continued odynophagia and chest pain. Chest CT showed wall thickening of the thoracic esophagus and no evidence of pulmonary embolus or mediastinitis. She was discharged again with instructions to continue the PPI and follow up with Gastroenterology. Two days later, she was noted to have ulceration in the posterior oropharynx and received intravenous hydration due to inability to tolerate liquids. Notably, her pain required narcotics. Antibiotics were discontinued and an esophagogastroduodenoscopy was performed. Severe, non-bleeding linear ulcers throughout the upper, middle, and lower esophagus were seen. HSV PCR of the esophageal biopsy was positive for HSV-1. She was treated with oral acyclovir for 10 days. On treatment, she improved rapidly and progressed to a solid diet. CD4 count was normal and HIV testing was negative. Repeat EGD 18 days later showed a 75% improvement in esophageal ulcers and repeat biopsies were negative. This illustrates a rare case of acute odynophagia and ulcerative esophagitis secondary to HSV-1 in an immunocompetent adolescent female. It is important to recognize that severe odynophagia is unlikely to be due to gastroesophageal reflux alone and may need referral for endoscopy. In such cases, the clinician must consider infectious causes such as candida, CMV, and herpes esophagitis regardless of immune status. The role of antiviral therapy is unclear, but is suggested in severe cases to shorten duration of illness.

A 13-Year-Old Boy with Pharyngitis, Oral Ulcers, and Dehydration

A13-year-old boy with no significant past medical history was admitted to our institution with pharyngitis, oral ulcers, and dehydration. He was well until 8 days prior to admission when he developed a fever to 103o F and pharyngitis. He was seen by his primary care physician, who ordered a rapid strep test and throat culture, both of which were negative, so symptomatic care was recommended. Four days prior to admission the patient developed ulcers on the inside of his mouth and lips. He was seen again by his primary care physician and started on antiviral medication and ibuprofen with hydrocodone, and a herpes simplex virus–polymerase chain reaction test was ordered. Mouth pain became so severe that the patient was unable to remain adequately hydrated. He was admitted to the hospital for pain control, intravenous fluids, and further work-up. In the 2 days prior to presentation to the hospital, he developed painful lesions on the glans of his penis. Recent medication use included NyQuil (Vicks), Theraflu (Novartis), Famvir (Novartis) and Vicoprofen (Abbott). The patient denied any history of sexual activity or Leanne W. Trapp, MD, is a Resident in Pediatrics, Comer Children’s Hospital, Pritzker School of Medicine, University of Chicago. Steven J. Schrantz, MD, Department of Medicine, Division of Infectious Diseases NorthShore University HealthSystem; and Clinical Assistant Professor, University of Chicago Pritzker School of Medicine. Monica A. Joseph-Griffin, MD, is Clinical Assistant Professor, Department of Pediatrics, NorthShore University HealthSystem; and Clinical Assistant Professor, Pritzker School of Medicine, University of Chicago. Joseph R. Hageman, MD, is Emeritus Attending Physician, Department of Pediatrics, NorthShore University HealthSystem; and Senior Clinician Educator, Pritzker School of Medicine, University of Chicago. Shoshana E. Waskow, MD, is an independent practitioner, Pediatric Associates of the NorthShore. Address correspondence to: Leanne W. Trapp, MD, Comer Children’s Hospital, 5721 S. Maryland Avenue, Chicago, IL 60637; fax: 773-834-0748; email: Leanne.trapp@uchospitals.edu. Disclosure: The authors have no relevant financial relationships to disclose. doi: 10.3928/00904481-20130326-06 Figure 1. Cracked, scabbed lips with ulcerations. Al l i m ag es c ou rte sy o f L ea nn e W . T ra pp , M D.

The Effectiveness of Rapid Strep A Test in the Diagnosis of Streptococcal Tonsillopharyngitis

The Effectiveness of Rapid Strep A Test in the Diagnosis of Streptococcal Tonsillopharyngitis

English

Enterococcus faecalis has emerged as an important nosocomial pathogen worldwide, infections and outbreaks of Vancomycin-resistant enterococci (VRE) still appear to be rare in Baghdad. In the present study, 20 isolates of E. faecalis were collected from 252 clinical samples (151 urine and 101 blood) from different hospitals in Baghdad and 3 isolates from 50 stool samples from healthy people during the period 1/10/2010 to 1/12/2010. All isolates were identified through morphological, cultural and biochemical tests using Rapid ID-32 strep. Vancomycin-resistance phenotype was determined by the agar diffusion method; results showed that five clinical isolates (25%) and two faecal isolates (66.7%)were resistant to vancomycin. Minimum inhibitory concentrations (MIC) of clinical VRE isolates ranged between 4 to 512 µg/ml and the MICs for isolates of faecal origin were 64 and 128 µg/ml. Seven vancomycin-resistant E. faecalis isolates were examined for their drug resistance and plasmid DNAs. Of the 5 clinical isolates, 2 isolates exhibited resistance to azlocillin (Azl) and ofloxacillin (Ofx). All clinical and stool isolates were resistant to oxacillin (Ox), cefepime (Fep), rifampicin (Ra) and tetracycline (Te). Imipenem and ampicillin were found to be the most effective agents against the isolates. The detection of plasmid DNA by gel electrophoresis showed that some E. faecalis isolates carried a high molecular weight plasmid that was transferred to the recipient by filter mating. The putative presence of vanA gene was examined by PCR, using specific primers. Positive PCR amplifications were obtained in all 7 isolates for vanA gene.Vancomycin resistant E. faecalis increased gradually in Baghdad hospitals and high dissemination of vanA gene, which encoded high resistance level to vancomycin. Continued surveillance is required to prevent further spread of these serious resistances. Key words: Bacteria, vancomycin, Enterococcus faecalis

Bacterial cultures, rapid strep test, and antibiotic treatment in infected hard-to-heal ulcers in primary care

Objective. In-depth studies on antibiotic treatment for patients with hard-to-heal ulcers in primary care are lacking. The present study was undertaken to update the bacteriological spectrum for this patient group and to investigate antibiotic treatment. A further aim was to investigate the potential of a rapid strep test to find group A streptococci (GAS) causing ulcer infection. Design. A prospective study from August 2009 to August 2010. Setting. Blekinge Wound Healing Center. Subjects. Patients with clinical signs of infected hard-to-heal ulcers of any etiology. Main outcome measures. A bacterial culture and a rapid strep test were taken from every ulcer to capture the bacteriological spectrum. Antibiotic treatment before and during the study period was measured. Results. Forty-one patients with 49 infected ulcers were recruited. Staphylococcus aureus, found in 68.8% of all cultures, was the most observed species. Group G streptococci (GGS) were found in 12.5%. GAS was found in one case where the rapid strep test was positive. Staphylococcus aureus was found in three patients out of four with clinical signs of erysipelas. Some 59% of the patients were treated with antibiotics before the study period compared with 44% during the study period. Conclusion. Antibiotic treatment was largely reduced because of structured wound management. The current bacteriological spectrum showed high rates of GGS and erysipelas caused by Staphylococcus aureus. The rapid strep test was found useful in identifying GAS but we would not recommend its use in the clinical setting due to the low rate of GAS in this patient group.

Use of Computed Tomography in the Emergency Department for the Diagnosis of Pediatric Peritonsillar Abscess

The objective of this study was to review our pediatric emergency department's (ED's) utilization of computed tomography (CT) in the diagnosis of peritonsillar abscess (PTA) and treatment outcomes. This study used case series with chart review. From January 2007 to January 2009, 148 patients were seen in our ED for possible PTA. Mean age at presentation was 11.8 years (range, 10 months to 18 years); 81 (54.7%) of 148 were females. Computed tomography was ordered in 96 (64.9%) of 148 patients, of which 73 (49.3%) 148 were confirmed to have PTA. Mean age of patients who underwent CT was younger when compared with those who did not have CT performed (mean, 11 vs 13 years; P = 0.02). Unilateral PTA was found in 65 (43.9%) of 148, bilateral in 8 (5.4%) of 148, and intratonsillar in 25 patients (16.9%). Concomitant CT findings of parapharyngeal space involvement were found in 19 (12.8%), and retropharyngeal space involvement in 11 (7.4%). Admission was necessary for 104 (71.2%) of 148 patients, whereas 42 were discharged from the ED. Transoral needle aspiration and/or incision and drainage were performed in the ED in 41 patients, with purulence identified in 33 (80.5%) of 41. Rapid strep testing was positive in 40 (32%) of 124 patients tested. Operative treatment was necessary in 44 patients (29.7%), 34 underwent incision and drainage, and 10 underwent quinsy tonsillectomy. Computed tomography is commonly utilized in the ED for the evaluation of PTA and is ordered more often in younger children.

Clinical Pearls in Dermatology

Clinical Pearls in Dermatology

Use of laboratory tests in out-of-hours services in Norway

Objective. To investigate the use of laboratory tests and which factors influence the use in Norwegian out-of-hours (OOH) services. Design. Cross-sectional observational study. Setting. Out-of-hours services in Norway. Subjects. All electronic reimbursement claims from doctors at OOH services in Norway in 2007. Main outcome measures. Number of contacts and laboratory tests in relation to patients’ and doctors’ characteristics. Results. 1 323 281 consultations and home visits were reported. Laboratory tests were used in 31% of the contacts. C-reactive protein (CRP) was the most common test (27% of all contacts), especially in respiratory illness (55%) and infants (44%). Electrocardiogram and rapid strep A test were used in 4% of the contacts. Young doctors, female doctors, and doctors in central areas used laboratory tests more often. Conclusion. CRP is extensively used in OOH services, especially by young and inexperienced doctors, and in central areas. Further investigations are required to see if this extensive use of CRP is of importance for correct diagnosis and treatment.

Simulated Pediatric Physician-Parent Email Cases

Abstract Physicians' use of electronic mail (email) communication with patients is increasing. A survey of American Academy of Pediatrics (AAP) members in 2001 reported only 14% used email with pat...

Group A β-hemolytic Streptococcal Infection at a Private Ear-nose-throat Clinic

We report 644 cases—411 cases in subjects aged 14 or under—of Group A β-hemolytic streptococcal infection. All children showed pharyngeal redness and “strawberry” tongue and were diagnosed with positive data from rapid strep testing. Subject number is peaked at the age 3, while fixed-point pediatrics observation peaked at age 5. The positive ratio of those reporting coughs exceeded that without coughs especially at age 5 or under. Fever, a significant complaint, affected the positive ratio at age 15 or over. Despite a chief complaint by 57 infected children of “ear pain”, 39 (68%) showed no signs of otitis media.

Rare Association of Crohnʼs Disease and Sweetʼs Syndrome: A Case Report

Purpose: A 43-year-old Caucasian female with a history of hypothyroidism, anxiety and a recent diagnosis of Crohn's Disease (CD), presented with four days of progressive itchy rash on both arms, fever, itchy eyes, arthralgias, and URI symptoms. Four weeks prior to this presentation, the patient was admitted with diarrhea. Work-up, which included a colonoscopy, revealed changes consistent with CD in the terminal ileum and the ileocecal valve. Patient was started on a combination of Entocort and azathioprine. Slowly, her CD symptoms slightly improved. Ten days later, the azathioprine dose was increased to 75 mg per day. One week following this dose adjustment, a series of new symptoms emerged. Patient noted tender red bumps that were multiplied in number and increased in size, covering her entire right upper arm and a few small red spots on the left arm. Mono Spot and Rapid Strep were both negative at that point. Patient was started on Hydroxyzine and Valacyclovir. Symptoms did not improve. On the morning of admission, patient had a temperature of 102.1 F. Her rash now covered her upper arms bilaterally. She had also developed a few small red spots on both her thighs. Exam was significant for very dramatic swollen lymph nodes on the anterior neck, multiple edematous redpurple color papules and plaques measuring 0.5-2 cm on bilateral upper arms and erythematous palpebral conjunctiva. Many of these had very edematous centers and almost looked vesicular and pustular in appearance. She also had scarce scattered 2 mm pinpoint erythematous papules on legs, trunk and back. Her lab results were remarkable for neutrophilia, elevated CRP and ESR. Subsequently, a punch biopsy was obtained. The azathioprine was discontinued with the suspicion that the lesion was secondary to medication side effects. The biopsy demonstrated a spongiotic epidermis with focal basal vacuolar changes and papillary edema. There was a dense diffuse infiltrate of mature neutrophils in the upper half of the dermis. Leukocytoclasis with formation of nuclear ducts was present but there was no evidence of vasculitis. The deep dermis and subcutaneous tissue were free of involvement. These findings are consistent with neutrophilic dermatosis and Sweet's Syndrome (SS). Prednisone 40 mg po daily was started for treatment of her SS. Patient's skin rash started to resolve with steroids and her conjunctivitis also improved. Patient was discharged on prednisone. Follow-up at five weeks post disposition confirmed that the patient was clear of any new welts and ocular symptoms. We recommend that SS be considered in the differential diagnosis in CD patients who develop skin lesions especially if the patients are started on drugs such as azathioprine.

Agranulocytosis secondary to propylthiouracil

A 36-year-old Caucasian female presented with sore throat, malaise and fever for 5 days. She was febrile and physical examination was remarkable for moderate pharyngeal erythema and mild tonsil hypertrophy. A complete blood count (CBC) showed a white blood cell (WBC) count of 810/µl [87% lymphocytes, 8% variant lymphocytes, 5% monocytes and an absolute neutrophil count (ANC) of zero], hemoglobin (Hgb) of 9.8 gm/dl, and a platelet count of 124 000/µl. A comprehensive metabolic panel, rapid strep screen, urine analysis and chest X-ray were unremarkable. She was admitted and empirically started on ceftriaxone and levofloxacin. The patient had no known drug allergies and a family history was significant for Graves’ disease (mother and three maternal aunts), and Factor V Leiden deficiency (father and sister). A review of the recent past medical history revealed an emergent cesarean section 4 weeks ago at 32 weeks of gestation secondary to abruptio placentae. Post-operatively the patient developed a pulmonary embolus followed by respiratory distress, tachycardia and thyrotoxicosis. During that hospitalization a CBC was unremarkable, TSH 0.005 ulU/ml, T4 16 ng/dl and T3 31.2 pg/dl, consistent …

Implementation of a Point-of-Care Satellite Laboratory (Kiosk) in the Emergency Department of an Academic Medical Center

In 2002, the Massachusetts General Hospital Clinical Pathology Division established a satellite laboratory staffed by laboratory-based medical technologists in our emergency department (ED "Kiosk") to perform a limited menu of rapid point-of-care tests. The initial menu included whole-blood cardiac markers, urine dipstick testing, urine pregnancy testing, and whole-blood glucose offered on the day shift only 5 d/wk. Implementation of these rapid tests resulted in an 87% decrease in turnaround time and was associated with a decrease in ED length of stay of 41 minutes for each patient tested. Since 2002, the menu and operations of the ED Kiosk have continued to evolve including the addition of new tests to the menu (rapid influenza, rapid RSV, rapid Strep A, urine drugs-of-abuse, and whole-blood d-dimer) and expansion of the hours of operation to 7 days, 24 h/d. Some of the new tests were shown to decrease ED length of stay (urine drugs-of-abuse testing, rapid d-dimer), whereas others were implemented to permit rapid diagnosis and triage of patients presenting to the ED. In this article, we describe our experiences with the operation of the ED Kiosk during an 8-year period.

Enterococcus hirae-associated endocarditis outbreaks in broiler flocks: clinical and pathological characteristics and molecular epidemiology

Background: Enterococcus hirae-associated endocarditis, characterized by a peak in mortality during the second week of the grow-out, and occasionally lameness, was diagnosed at Dutch broiler farms. Objectives: Field cases were studied to increase knowledge on clinical and pathological characteristics, pathogenesis and epidemiology of these infections. Animals and methods. In total, 1266 birds of 25 flocks from 12 farms were examined. Post-mortem examinations, bacteriology, histopathology, PCR and DNA fingerprinting was carried out. Six flocks were followed longitudinally (n = 1017 birds). Results: Average mortality was 4.1% for the entire grow-out, of which 36% was attributed to endocarditis. Fibrinous thromboendocarditis of the right atrioventricular (AV) valve was found in 24% of hearts, compared to 7% and 4% with lesions of left and both AV valves, respectively. Thrombotic lesions were found in 24% (n = 432) of lungs, but only in larger branches of the Arteria pulmonalis. Occasionally, thrombi were found in the Arteria ischiadica externa and in liver and brain vessels. Enterococcus was cultured from 54% (n = 176) of heart and in 75% (n = 28), 62% (n = 106) and 31% (n = 16) of liver, bone marrow and lung samples, respectively. Further identification, using the Rapid ID Strep 32 API system and a PCR targeting mur-2 and mur-2ed genes was carried out on a subset of Enterococcus positive isolates (n = 65): both techniques identified the isolates as Enterococcus hirae. Pulsed-field gel electrophoresis did not indicate evidence of clonality between farms and flocks. Conclusions: The relevance of these findings for pathogenesis and epidemiology of E. hirae infections is discussed. Clinical importance. This study may facilitate diagnosis of field cases and may contribute to the design of further research and development of control measures.

Decriminalize prostituted women

Beta-hemolytic group A streptococcus is the most common bacterial agent associated with pharyngitis. Rapid antigen detection tests should be used to diagnose pharyngitis (tonsillitis) due to <i>Streptococcus pyogenes</i> infection in order to make a sure diagnosis and to reduce usage of antibiotics. <h3>Material and Methods</h3> A prospective study was conducted among 116 children (70 girls, 46 boys) aged 2–14 years (mean age 5.9 years, SD 2.6 years). Inclusive criteria to the study were: fever &gt;38°C and sore throat. None of the children received antibiotics prior to testing. In all children, a rapid streptococcal test (Test Strep A®, SureScreen, UK) and conventional culture from the pharyngeal swabs were performed. <h3>Results</h3> The rapid streptococcal test was positive in 16 patients (13.7%) while culture was positive in 14 (12%) patients. Among all positive rapid strep tests there were 12 true positive and 4 false positive. Among negative rapid strep tests 98 were true negative and 2 false negative. The sensitivity of a rapid strep test was estimated as 86% and specifity as 96%. The sensitivity (86%) was lower than shown in a product monograph (97%, 95% CI 91% to 99%) while the specifity (96%) was comparable with data shown in a description provide by producer (95%, 95% CI 92% to 97%). <h3>Conclusions</h3> The examined rapid strep test (Test Strep A®) was less sensitive than it was suggested in the product monograph, but the sensitivity of 86% and specifity of 96% reached in ambulatory conditions are still high enough to find this test useful for clinical usage.

Characterization ofStreptococcus milleriGroup Isolates from Expectorated Sputum of Adult Patients with Cystic Fibrosis

With the recent insights into the Streptococcus milleri group (SMG) as pulmonary pathogens in patients with cystic fibrosis (CF), we sought to characterize 128 isolates from the sputum of adults with CF, along with 45 isolates from patients with invasive diseases for comparison. The tests performed included Lancefield grouping; tests for hemolysis; tests for the production of hyaluronidase, chondroitin sulfatase, DNase, proteases, and hydrogen peroxide; and PCR for the detection of the intermedilysin gene (ily). We also generated biochemical profiles with the Rapid ID Strep 32 API system and tested cell-free supernatants for the presence of the signal molecule autoinducer-2 (AI-2) using a Vibrio harveyi bioassay with a subset of CF strains. The S. intermedius isolates from both strain collections were similar, while the S. constellatus and S. anginosus isolates yielded several biotypes that differed in prevalence between the two strain collections. Beta-hemolytic, Lancefield group C S. constellatus comprised 74.4% of the S. constellatus isolates from patients with CF but only 13.3% of the corresponding isolates from patients with invasive infections. This was the only S. constellatus biotype associated with pulmonary exacerbations. Hyaluronidase-positive S. anginosus was detected only among the isolates from patients with CF. Strain-to-strain variability in AI-2 expression was evident, with the mean values being the highest for S. anginosus, followed by S. constellatus and then S. intermedius. Cluster analysis and 16S rRNA sequencing revealed that the species of SMG could be accurately determined with a minimum of three phenotypic tests: tests for the Lancefield group, hyaluronidase production, and chondroitin sulfatase production. Furthermore, isolates from patients with invasive infections clustered with isolates from the sputum of patients with CF, suggesting that the respiratory tract isolates were equally pathogenic.

Impact of Rapid Streptococcal Test on Antibiotic Use in a Pediatric Emergency Department

Acute pharyngitis is commonly seen in children. Group A beta-hemolytic Streptococcus is the most common bacterial cause of acute pharyngitis and accounts for approximately 15% to 30% of cases in children, but this condition is generally overdiagnosed and overtreated. The availability of rapid streptococcal tests (RSTs) have made this diagnosis simpler and reduced the use of antibiotics. Overuse of antibiotics leads to drug-resistant bacterial strains. Reducing the number of antibiotic prescriptions provided for upper respiratory tract infections has been strongly recommended to limit bacterial resistance. To assess the impact of RSTs on antibiotic prescriptions in children with pharyngitis in the emergency department. A retrospective study from September 2005 to September 2007 of all patients (3-18 years old) presenting to the pediatric emergency department with sore throat as the chief complaint or suspected clinically to have acute pharyngitis and who had an RST performed. Patients with a negative RST result had a culture performed. The information of the patients with the diagnosis of pharyngitis was also collected in a 2-year control period before the availability of the test. Patients with a negative RST result had a culture performed. In addition, the antibiotic prescriptions for these patients were also recorded. A total of 8280 patients were included in the study. Throat culture results of 1723 patients were reviewed in the pre-RST phase. During the post-RST phase, 6557 children underwent RST. The RST results were positive in 1474 children (22.5%) and negative in 5083 patients (77.5%). Rapid strep testing was associated with a lower antibiotic prescription rate for children with pharyngitis (41.38% for those treated in the pre-RST phase versus 22.45% for those treated in the post-RST phase; P < 0.001). The availability of a RST could substantially reduce the unnecessary prescription of antibiotics. This study supports the screening of all children with pharyngitis by performing an RST to guide decision making for antibiotic administration. This strategy has a significant impact on reducing the antibiotic prescription rate to almost 50%. In addition, only 2 children (0.04%) had negative rapid antigen test results with cultures positive for Streptococcus.

Role of Non-Group A Streptococci in Acute Pharyngitis

The role of non-group A streptococci (non-GAS) as pathogens of acute pharyngitis is controversial. Data are limited and conflicting on whether these bacteria are true pathogens of pharyngitis and whether treatment is indicated in all cases or just select cases. However, non-GAS are well-documented as being pathogens of other diseases, including neonatal sepsis, pneumonia, endocarditis, and urinary tract infections. If non-GAS are pathogens of acute pharyngitis, treatment may speed recovery as well as prevent complications. The objective of this study was to determine whether, in cases of pharyngitis in which non-GAS is identified on culture, the clinical signs and symptoms resemble those of group A streptococcal pharyngitis thus implicating them as true pathogens or if they resemble culture-negative pharyngitis, suggesting these cases are viral in etiology. This was a 3-group retrospective case-control study (N=915; mean age, 26 years). Cases included all patients with non-GAS identified on culture (n=180). The control group 1 consisted of all patients with GAS infection identified by a rapid strep test or culture (n=145); control group 2 included all patients with a negative rapid strep test and culture (presumed viral pharyngitis; n=584). Multivariate analysis was used to compare the prevalence of 5 clinical features among the groups. The presence of headache and fever was significantly associated with streptococcal infection, with no difference between GAS and non-GAS infection. Exudates and lymphadenopathy were also significantly associated with both GAS and non-GAS infection compared with viral infection. When 2 criteria were present, the risk of any streptococcal infection rose to 55% (27% for non-GAS or GAS); when 3 or more criteria were present, the rate of any streptococcal infection rose to 81% (non-GAS infection, 34%; GAS infection, 47%). In this predominantly young, adult population with acute pharyngitis, non-GAS infection was as common as GAS infection and was associated with the same clinical features typically associated with GAS. Although the benefits of treating non-GAS pharyngitis in terms of either symptomatic relief or prevention of sequelae are unproven, clinicians may want to consider treating patients with proven or presumptive non-GAS pharyngitis who fail to respond to symptomatic therapy or who are at increased risk for sequelae of group B or group C streptococcal infections, such as those patients who are or have close contact with pregnant women, neonates, and elderly or immunocompromised persons. Further study is needed to determine whether patients with non-GAS pharyngitis benefit from targeted antibiotic treatment.

A Foundation of Failure

A Foundation of Failure