Strep Throat 2023

 

Strep Throat 2023

Strep throat is a bacterial infection most commonly caused by the Group A streptococcus bacteria. There are other strains of strep bacteria (Group D, Group G, and others), which can cause sore throats, but typically heal on their own without treatment and do not lead to serious concerns.

Classic strep throat illness is most common in school-aged kids, but people of any age can get it. It is quite unusual for babies under 2 years of age to have it, but there are always exceptions. This age preference is due to the receptors on tonsil tissue between the ages of 5 and 15, which have a much greater affinity for the strep bacteria than at any other age. 

Symptoms

Someone with strep throat will usually present with one or more of these:

• Sore throat
• Fever
• Body aches
• Headache
• Stomach ache
• Nausea
• Dizziness
• Smelly breath
• A red sandpapery rash all over the body that starts in the armpits
• In kids under 5, the primary symptom might be more congestion than sore throat
• NOTE: Typically the strep throat 'package' does not come along with a lot of congestion. If I am hearing about an older child with lots of coughing, clear mucus and sore throat, it is more likely viral.

Strep with the rash may be referred to as Scarlet fever...sounds scary right?? Indeed it used to be. Now that we have antibiotics to treat it, strep throat with Scarlet Fever is not much more alarming than simple strep.

Get out your little flashlight and do some checking. If you are lucky enough maybe they will actually open their mouth; most of the time the throat will look quite red. You may see red or white patches in the throat or on the palate (the back part of the roof of the mouth.)

The tongue might have red and white patches. This is referred to as strawberry tongue for obvious reasons. Feel around the neck and see if the glands feel swollen. Sniff the breath. Often parents call me and say that it smells like their kids swallowed a 'swamp creature'. The breath smells yucky.

Not everyone has all the symptoms.

Be aware that children under 5 often say that their "mouth" or “neck” hurts, but they are talking about their throat.

Some folks don't even complain about a sore throat and some cases don't present with an elevated temperature.

Complaining of tummy and headache with sore throat should significantly increase your suspicion for strep throat, especially in the absence of cough and congestion.

While nausea and tummy aches are quite frequent with strep, add diarrhea to the mix and I am no longer as suspicious. Nausea plus loose stools is usually more of a tummy bug of sorts.

Contagiousness

Strep throat is quite contagious, but it is not uncommon for some family members to have it, while others escape. Remember the difference in tonsil tissue by age? Because of this, some parents might not get strep throat infections from their kids. I would say that in my experience the odds are about 50/50. (The minute someone in your family gets that sore throat I would suggest sucking on a zinc lozenge and some Sambucol; maybe you will get lucky.)

Some patients also seem way more susceptible to strep than others. I used to get it all the time until I had my tonsils out. That is not an uncommon story. 

The incubation period ranges from 1-5 days but most of the time folks show the first symptoms about 2-3 days after exposure. You can catch it from being in close contact with someone else who has it. If you treat with antibiotics (which is recommended) you are not contagious once you have completed 24 hours of the medication. If you don't treat it, you remain contagious and can spread the illness for about 3 weeks.

How to avoid strep:

Strep throat, while very contagious in school-aged children, is easy to avoid with good technique. Since it lives on surfaces, good old fashioned hand hygiene is very effective at decreasing spread.

• Wash hands well with soap and water
• Wiping down surfaces, especially in the bathroom, kitchen, doorknobs, and cell phones, makes a difference
• Don’t apologize for wearing a mask in a crowd
• Avoid swapping spit, sharing drinks, etc
• Replace toothbrushes for household contacts with strep

Do you need treatment?

Given enough time, strep can resolve by itself but the antibiotics absolutely shorten the severity and duration of the illness, decrease the infectiousness to others, and significantly decrease the risk of complications. Untreated strep throat can lead to complications later on, such as rheumatic fever and heart valve problems.

It is impossible to have real statistics about this. Most folks don't jump into the doctor's office every time they have a sore throat. There are likely millions of untreated cases of strep out there at any given time and of course most of them will have no issues in the future. However, better safe than sorry. If we know you have a case of strep throat, we will strongly advise that you do a course of antibiotics.

Testing for strep:

Many doctor’s offices will test with a rapid NAAT test that is very reliable (it’s like PCR). With the newer technology, most offices are no longer sending swabs out for culture (the 24 hour result).

If your child hates the swab there are 2 things you can do to help.

1. First is to have them lift their legs when they are saying AAAAH. The brain gets confused by this and forgets to gag.
2. Another tip that I learned from a 3 year old patient is to growl like a lion. The growling is the perfect way to open up the throat and the mouth for that swab to sneak in.

Most in-office testing specific for Group A strep. There are different strains of the strep bacteria that can cause various infections. If the in-office test is negative, and you’ve had chronic (more than a week) symptoms, it is sometimes possible to test for other forms of strep bacteria by asking for a special test to be sent out to a lab. Ask your provider about this.

A note on strep “carriers:

Some folks are carriers. This means that they have a small amount of the bacteria living in their body all of the time and it doesn't make them ill. Those folks may be positive all the time on testing, even when they feel well. This gets confusing, because they might separately catch a virus, go to the office, get tested for strep, turn out positive, but the strep bacteria wasn’t causing their symptoms. Unless you know you’re a carrier, it’s usually worth it to simply treat a positive result.

Symptomatic treatments until the antibiotics kick in

• Tylenol or Motrin (we are treating pain, not necessarily fever)
• Lozenges
• Tea with honey (no honey for kids until one year old)
• Check out Manuka honey if you can find it. Not all honey is created equal.
• Gargling with salt water
• Popsicles
• Cold fruit nectar
• Having a humidifier running at night.

Antibiotic treatment

There are two most common oral antibiotics, and a shot is available for children that are unable to tolerate oral antibiotics.

• Amoxicillin: great taste, and can be given once a day every day for 10 days (much easier than two or three times a day like it used to be)
• Penicillin: vile tasting liquid, so not recommended for little kids. In its pill form, it needs to be given 2-3 times per day, but has a more “narrow spectrum” aka can preserve the gut microbiome better than amoxicillin. Be aware, the urine might smell funky during treatment.
• Penicillin injection: one and done, but it’s large and painful. Best for kids that absolutely cannot tolerate medicine or are vomiting.
• For people who are allergic to penicillin or amoxicillin: azithromycin can be given daily for 5 days, but please note that it’s at a higher dose than what is used for ear infections or pneumonia.

If you do end up being treated with antibiotics, it is important that you finish the entire course. If you are not seeing an improvement within 72 hours of starting the medication, make sure you check in with your doctor. It is rare, but strep can lead to serious complications including abscesses on the tonsils, ear infections as well as kidney problems.

Some studies conclude that if you do end up on antibiotics, taking probiotics can help keep a healthy gut.

A national shortage of Amoxicillin was announced by the FDA in late October 2022 and as of November 2023 there is no end in sight. It is the powder that is used to make the liquid that is in short supply. Fortunately here in the Bay Area, patients don't seem to be having issues. (Thank you to Dr. Sophia and Dr. Ted)

If you are living in an area where you are having trouble finding it, It might be time for your older kid to learn how to swallow pills

My post on giving medications gives some tips for how to teach them to do that

 

Change your toothbrush 24 hours after starting the antibiotics so that you don't get reinfected!

Rare complications

There are some exceedingly rare complications of strep throat that should not occupy your mind but are nonetheless good to know about in case some of their unique symptoms appear after strep:

• Abscesses: shortly after or during infection, pus can collect in the spaces behind the mouth and throat in the neck. This is serious and often requires an emergency room visit. These children will have extremely high fever, a “hot potato” voice (very muffled), and an inability to close their mouth or turn their head. They are often drooling excessively.
• Rheumatic fever: a serious fever that develops 2-4 weeks after strep throat infection. It has an autoimmune cause, and can be associated with joint pains, involuntary movements, and heart valve problems. Treating the initial strep infection with antibiotics will reduce the risk of this by about 70%. 
• Post-streptococcal glomerulonephritis (say that five times fast): an extremely rare condition in the US, it’s characterized by decreased urination about 2-3 weeks after infection. The urine that comes out is very dark, possibly bloody. There may be puffiness in the face and arms. This is not typically associated with a fever.
• PANDAS (Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci, say that ten times fast): an even more extremely rare disorder, this is an autoimmune condition characterized by the extremely abrupt exacerbation or onset of OCD disorder or tic disorder symptoms. The timing can be weeks to months after strep infection, and treatment remains poorly understood. Time seems to improve symptoms, but pediatric rheumatologists and infectious disease doctors can use steroids or naproxen. 

Giant shout out to Dr. Ted. We have so much fun diving through updated data while we work on these, as well as going down some remarkable rabbit holes along the way.