Endemic year-round GABHS pharyngitis has its peak occurrence in the late winter and early spring.1 After an incubation period of 2 to 5 days, patients develop the sudden onset of sore throat, painful swallowing, chills, and fever. Headache, nausea, vomiting, and abdominal pain are common associated symptoms.
On physical examination of patients with typical GABHS, there are erythematous tonsils, discrete tonsillar exudate; enlarged, tender anterior cervical lymph nodes; and uvula edema. Often, palatal petechiae accompany the marked erythema of the throat and tonsils. Viral and bacterial agents often present with a more vesicular and petechial pattern on the soft palate and tonsils of the pharynx and no exudate. Clinical differentiation between viral and bacterial infection can be difficult.
Throat culture remains the most effective method for diagnosis. A single throat swab cultured correctly on a blood agar plate has a sensitivity of 90 to 95 percent in detecting the presence of a GABHS.3 A disadvantage of culturing a throat swab is the delay in obtaining the culture results. Rapid antigen detection tests (RADTs) have been developed for the identification of GABHS directly from throat swabs. Most of the RADTs currently available have an excellent specificity (>95 percent) compared to blood agar plate cultures.4 Either a positive throat culture or RADT result provides adequate confirmation of the presence of GABHS in the pharynx, but a negative RADT result should be confirmed with a throat culture.
All patients with pharyngitis should receive symptomatic treatment. Gargling with warm saltwater, drinking warm liquids, and rest are important. Patients unable to tolerate oral fluids or who become dehydrated should be given intravenous fluids. Young children and geriatric patients should be carefully assessed for their ability to remain well hydrated.
A number of antibiotics are effective against GABHS. These agents include penicillin and its congeners (e.g., ampicillin and amoxicillin), as well as numerous cephalosporins, macrolides, and clindamycin. However, penicillin remains the drug of choice because of its proven efficacy, safety, narrow spectrum, and low cost. Erythromycin is a suitable alternative for patients allergic to penicillin. First- or second-generation cephalosporins are also acceptable for penicillin-allergic patients who do not manifest immediate hypersensitivity. Most oral antibiotics, except the newer macrolides, must be administered for 10 days to achieve maximal pharyngeal eradication of GABHS. It has been reported that azithromycin, cefuroxime, cefixime, and cefpodoxime can be used to achieve comparable bacteriologic and clinical cure rates among patients with streptococcal pharyngitis when given for less than 5 days.3 Close contacts and family members should be cultured, and those whose results are positive should be treated.
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