para>Avoid aspirin in children due to risk of Reye syndrome.
ISSUES FOR REFERRAL
Peritonsillar abscess; shock symptoms: hypotension, disseminated intravascular coagulation (DIC), cardiac, liver, renal dysfunction
SURGERY/OTHER PROCEDURES
- Tonsillectomy is recommended with recurrent bouts of pharyngitis ( ≥6 positive strep cultures in 1 year).
- While children still may get streptococcal pharyngitis ( "strep throat " ) after a tonsillectomy, the procedure reduces the frequency and severity of infections.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Follow-up throat culture is not needed unless the patient is symptomatic.
Patient Monitoring
GAS is uniformly susceptible to penicillin, treatment failures are typically due to:
- Poor adherence to recommended antibiotic therapy
- ²-Lactamase oral flora hydrolyzing penicillin
- GAS carrier state and concurrent viral rash (requires no treatment)
- Repeat exposure to carriers in family: Streptococci persist on nonrinsed toothbrushes and orthodontic appliances for up to 15 days.
- Recurrent GAS pharyngitis after a recent oral antibiotic course can be retreated with the same agent, an alternative oral agent, or IM penicillin G.
DIET
No special diet
PATIENT EDUCATION
- A brief delay in initiating treatment awaiting culture results does not increase the risk of rheumatic fever.
- Complete the entire course of antibiotics.
- Children should not return to school/daycare until they have received >24 hours of antibiotic therapy.
- Can spread person to person: attend to personal hygiene (wash hands, don " t share utensils)
- "Recurring strep throat: When is tonsillectomy useful? " (http://www.mayoclinic.org/diseasesconditions/strep-throat/expert-answers/recurringstrep-throat/faq-20058360)
PROGNOSIS
- Symptoms are shortened by 12 to 24 hours with penicillin.
- Recurrent attacks are possible (different erythrogenic toxins).
COMPLICATIONS
- Suppurative
- Sinusitis
- Otitis media/mastoiditis
- Cervical adenitis
- Peritonsillar abscess/retropharyngeal abscess
- Pneumonia
- Bacteremia with metastatic infectious foci: meningitis, brain abscess, osteomyelitis, septic arthritis, endocarditis, intracranial venous sinus thrombosis, necrotizing fasciitis
- Nonsuppurative
- Rheumatic fever: Therapy prevents rheumatic fever when started as long as 10 days after onset of acute GAS infection.
- Glomerulonephritis: due to nephritogenic strain of Streptococcus; prevention even after adequate treatment of GAS is less certain
- Streptococcal toxic shock syndrome: fever; hypotension; DIC; and cardiac, liver, and/or kidney dysfunction related to other toxin-mediated sequelae
- Cellulitis
- Weeks to months later, may develop transverse grooves in nail plates and hair loss (telogen effluvium)
REFERENCES
11 Choby BA. Diagnosis and treatment of streptococcal pharyngitis. Am Fam Physician. 2009;79(5):383 " 390.22 Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):1279 " 1282.33 University of Michigan Health System. Pharyngitis. Ann Arbor, MI: University of Michigan Health System; 2013. National Guideline Clearinghouse Guideline Summary NGC-9967.44 Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009;119(11):1541 " 1551.55 van Driel ML, De Sutter AI, Keber N, et al. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2013;(4):CD004406.66 Lennon DR, Farrell E, Martin DR, et al. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child. 2008;93(6):474 " 478.
SEE ALSO
- Pharyngitis
- Algorithm: Pharyngitis
CODES
ICD10
- A38.9 Scarlet fever, uncomplicated
- J02.0 Streptococcal pharyngitis
- A38.0 Scarlet fever with otitis media
- A38.8 Scarlet fever with other complications
ICD9
- 034.1 Scarlet fever
- 034.0 Streptococcal sore throat
- 422.0 Acute myocarditis in diseases classified elsewhere
SNOMED
- 30242009 Scarlet fever (disorder)
- 186357007 streptococcal sore throat with scarlatina (disorder)
- 1090001000119105 Otitis media due to scarlet fever (disorder)
- 128870005 Crusted scabies (disorder)
- 1089931000119105 Myocarditis due to scarlet fever (disorder)
CLINICAL PEARLS
- Consider scarlet fever in the differential diagnosis of children with fever and an exanthematous rash
- Key clinical findings include strawberry tongue, circumoral pallor, and a coarse sandpaper rash
- Desquamation (7 to 10 days after symptom onset) may last for several weeks following acute illness in scarlet fever.
- Throat culture remains the diagnostic test of choice to document streptococcal illness.
- Penicillin is the drug of choice for treatment.