Streptococcus Pharyngitis (strept throat): CENTOR Criteria

Streptococcus Pharyngitis (strept throat): CENTOR Criteria

  1. History of fever or measured temp greater than 38C or 100.4F
  2. Tonsillar swelling or exudates
  3. Tender anterior cervical lymph nodes
  4. Absence of a cough
Source: http://www.essentialevidenceplus.com/content/eee/577

Source: http://www.essentialevidenceplus.com/content/eee/577

A rapid antigen detection test (RADT) can be used to rule out strep throat in patients with intermediate probability of strep pharyngitis.

  • ***Order: [Group A Strept Screen]***

–  Ex: The patient has 4 out of 4 Centor criteria met, so she is empirically treated with Cephalexin 500mg PO bid for 10 days. Rapid Strept throat swab screen was negative. Throat culture has been ordered. She is encouraged to stay well hydrated and to get plenty of sleep. For her sore throat, she is encouraged to gargle salt water.

The Infectious Diseases Society of America (IDSA) recommends RADT for all patients with pharyngitis except for children under age 3 years or when sore throat is accompanied by overt viral features like rhinorrhea, cough, oral ulcers, and hoarseness. In children and adolescents with negative RADTs, the IDSA recommends throat culture.

The patient’s sore throat is likely secondary to strept. pharyngitis as the patient does not have an accompanying viral picture (rhinorrhea, itchy eyes, cough), and she has tonsillar swelling, exudates, tender anterior cervical nodes, and an absence of a cough.

  • Order a Strept swab screen on throat. Sx: sore throat, lymphadenopathy, pharyngeal erythema
    1. If positive: Strept pharyngitis
      • Tx: Amoxicillin 500mg PO bid or tid for 6-10 days.
        • Penicillin is the drug of choice for adults and a cephalosporin is recommended for children.
          • Penicillin allergy: Azithromycin 250mg tablets – Take 2 tablets on day 1 and 1 tablet for the following 4 days.
        • Acetaminophen is recommended for throat pain; aspirin should be avoided in children due to the risk of Reye’s syndrome
      • Patient will be able to return to school/work 48 hours after initiating antibiotic treatment.
    2. If negative:
      • Likely viral Recommended good hydration and plenty of rest.
        • Today we discussed:
        • Acute viral pharyngitis: The patient meet 3 out of the 4 Centor Criteria. She has tonsillar swelling and exudates, she has tender anterior cervical lymph nodes, and there was an absence of a cough. The only criteria that she did not have was a fever. Therefore, a rapid Strept. screen was performed in the clinic today, which was negative for Strept, so she does not have a bacterial cause for her pharyngitis. No antibiotics were prescribed today. Conservative management is encouraged, which includes salt water gargle to relieve her sore throat, stay well hydrated, and get plenty of sleep. Acetaminophen is recommended for throat pain
        • Right ear and right throat discomfort secondary to Eustachian tube dysfunction: Acute viral pharyngitis can cause inflammation and subsequent swelling of the Eustachian tube, which leads to right ear pain and right throat discomfort. The patient was reassured that this discomfort should resolve on its own as the etiology is viral in nature. The patient had cerumen impaction of the right ear as well, so this was also removed during this appointment to allow for better visualization of the TMs and may help alleviate some of her right ear discomfort. No signs of acute otitis media were visualized follow cerumen removal.
      • Other things on differential:
        • Mono screen: Order Monospot Rapid Mono Test. (Heterophile antibody test)
          • Heterophil antibody test is positive for infectious mononucleosis. False-negative heterophil testing is common early in the disease course.
          • Presents most commonly with a sore throat, fatigue, myalgias, and lymphadenopathy, and is most prevalent between 10 and 30 years of age.
          • Tx: supportive including hydration, NSAIDs, throat sprays/lozenges (cough drops)
            • In general, corticosteroids do not have a significant effect on the clinical course of infectious mononucleosis, and they should not be used routinely unless the patient has evidence of acute airway obstruction.
          • Tell patient to not play any contact sports (enlarged spleen may get ruptured).
            • Patients with mononucleosis have splenomegaly (even if not palpable): Patients should be advised to avoid contact- or collision-type activities for 3–4 weeks because of the increased risk of rupture (of enlarged spleen).
          • Flu: fever/Sx <2 days (<48 hours), can start Tamiflu. Order Influenza A/B antigen screen (flu)

Supportive therapy recommended: Drink plenty of water. Get plenty of sleep. Sore throat: gargle with salt water and use OTC cough drops. Can use OTC Chloraseptic spray to relieve the sore throat.

–  Sore throat: Chloraseptic 1.4 % Mouth/Throat Liquid

 

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