Pediatric Primary Care (58 page)

d.  Mycoplasma pneumoniae: possibly 10% occurence in adolescents.

e.  Corynebacterium diphtheriae.

B.  Occurrence.

1.  Peak incidence late fall through early spring.

2.  Younger children more commonly present in winter months and with viral pharyngitis.

3.  GABHS has proclivity for 5- to 15-year age group, also peaking in winter.

C.  Clinical manifestations.

1.  Viral pharyngitis.

a.  Gradual onset.

b.  Cough, coryza, diarrhea more common.

2.  Coxsackievirus (see “Physical findings”–next section)

3.  Streptococcal.

a.  Rapid onset.

b.  See “Physical findings”–next section.

D.  Physical findings.

1.  Viral pharyngitis.

a.  Sore throat, dysphagia.

b.  Low-grade fever.

c.  Possibly diarrhea.

2.  Coxsackievirus.

a.  Fever, headache.

b.  GI complaints.

c.  Possibly papular rash of hand, foot, mouth disease.

d.  Possibly ulcerative lesions in mucosa of mouth.

3.  Streptococcal GABHS.

a.  Moderate to high fever, headache.

b.  Red pharynx: beefy red, swollen uvula and tonsils.

c.  Yellow, blood: tinged exudates.

d.  Petechiae on soft palate, strawberry (coated) tongue.

e.  Tender cervical lymphadenopathy.

f.  Multiple GI complaints.

g.  Accompanying scarlatiniform rash: red, sandpaper-like, clustered in body's “hot spots” (axillae, neck, inguinal, anticubital, popliteal areas).

E.  Diagnostic tests.

1.  Throat swab for rapid antigen detection test for GABHS. Negative should also have follow-up throat culture (can also identify carrier state).

2.  Heterophile antibody test for EBV.

3.  CBC.

F.  Differential diagnosis.

1.  Viral vs. bacterial entity.

a.  Infectious mononucleosis.

b.  Group C or G streptococcus.

2.  Allergic rhinitis.

G.  Treatment.

1.  Nonpharmacologic.

a.  Encourage fluids: may prefer hot or cold for pain relief.

2.  Pharmacologic.

a.  Topical and oral analgesics and antipyretics.

b.  Antimicrobials: penicillin V recommended.

•  Children < 27 kg: 250 mg bid or tid for 10 days.

•  Children > 27 kg: 500 mg bid or tid for 10 days.

•  IM benzathine penicillin G: if compliance, vomiting issues.

i.   Children < 27 kg: 600,000 units.

ii.  Children > 27 kg: 1.2 million units.

•  Amoxicillin: substituted for taste issues (may benefit 40% of children with adenotonsillar disease, who yield beta-lactamase-producing bacteria).

i.   Once daily dosing of amoxicillin at 50 mg/kg for 10 days is as effective as penicillin V or amoxicillin given in multiple doses for 10 days.

•  Penicillin (PCN) allergic options:

i.   Clindamycin (20 mg/kg/day in 3 divided doses, max 1.8 g/ day). In the United States, macrolide resistant rates to group A streptococci (GAS) have been 5-8%.

ii.  Erythromycin estolate or ethylsuccinate: 40 mg/kg/day in 2-4 divided doses.

iii. Clarithromycin: Child: 15 mg/kg/day, max: 1000 mg divided q12h for 10 days. Adult: 500 mg q12h for 10 days.

iv. Azithromycin: 12 mg/kg/day for 5 days.

•  First-generation cephalosporin such as cephalexin: also appropriate if retreatment necessary.

•  
Note:
As many as 5% of penicillin-allergic people are also allergic to cephalosporins. People with type 1 allergy to PCN should not be treated with a cephalosporin.

•  Due to increased treatment failure with PCN, some clinicians are using a first generation cephalosporin in all nonallergic patients.

i.  Cephalexin (25-40 mg/kg/day in 2 divided doses for 10 days).

•  Other cephalosporins also have indication for GAS treatment:

i.   Cefprozil (second generation).

ii.  Cefpodoxime, cefdinir (third generation).

•  If illness recurs shortly after treatment:

i.   May be retreated with same drug.

ii.  IM penicillin if compliance an issue.

iii. Narrow-spectrum cephalosporin (cephalexin).

iv. Amoxicillin-clavulanate potassium.

H.  Follow up.

1.  Routine reculturing is not necessary.

2.  Encourage patients to call if:

a.  Unable to complete course of medication or retain medication.

b.  Siblings complain of sore throat within 2-5 days: amoxicillinxclavulanate 90 mg/6.4 mg per kg/day. If allergic: 6 months to 12 years of age, cefdinir 7 mg/kg bid or 14 mg/kg daily; 13 years, 300 mg bid 10 days.

c.  No improvement in patient in 48 hours.

d.  Signs and symptoms of renal complications.

e.  Drug reaction.

3.  Possible assessment of carrier state which is common and patients are low risk to transmit and develop invasive disease. Most common scenario is a carrier who is experiencing repeated intercurrent episodes of viral pharyngitis. (In true GAS pharyngitis response to antimicrobial therapy is rapid.) Treatment of carriers is indicated only in very specific cases such as those involving rheumatic fever or glomerulonephritis outbreaks or recurrent, symptomatic GAS pharyngitis in a family after appropriate therapy.

a.  Clindamycin most effective treatment (20 mg/kg/day in 3 divided doses; max 1.8 g/day).

b.  ENT referral for possible tonsillectomy and adenoidectomy, though currently poorly understood and risks of surgery often do not outweigh possible benefits.

•  Multiple bouts of tonsillitis in 1 year despite adequate treatment.

•  Significant upper airway obstruction.

•  Peritonsillar abscess.

I.  Complications.

1.  Streptococcal pharyngitis.

a.  Suppurative.

•  Peritonsillar abscess.