While 80 percent of pharyngitis is viral in etiology, Group A streptococcus (GAS) remains an important cause of pharyngotonsillitis in the pediatric population.
Inappropriate testing for GAS pharyngitis inevitably leads to overuse of antibiotics, which can result in a pitfall of treatment with an inappropriate antimicrobial agent.
Join Dr. Myers, MD, MPH to learn more about an algorithm your office can use to optimize testing and treatment of GAS pharyngitis, avoiding the five most common pitfalls in diagnosis and treatment of GAS Infection.
The Five Most Common Pitfalls in Diagnosis and Treatment of Group A Streptococcal Infection
Featured Speaker:
Learn more about Angela Myers, MD
Angela Myers, MD, MPH
Angela Myers is the Pediatric Infectious Diseases Fellowship Program Director, and Medical Director of Travel Medicine with Children’s Mercy Kansas City. She received her medical degree from the University of Missouri-Kansas City School of Medicine, Kansas City, MO and her master’s of public health from the University of Kansas School of Medicine, Kansas City, KS. She completed a pediatric residency and pediatric infectious diseases fellowship with Children’s Mercy. She is certified in pediatrics and pediatric infectious diseases with specialties in Pertussis, Group A streptococcal infections, adverse drug reactions of common pediatric antibiotics, health care worker immunization mandates and practices, and childhood vaccines. She is also an Associate Professor of Pediatrics at the University of Missouri-Kansas City School of Medicine.Learn more about Angela Myers, MD
Transcription:
The Five Most Common Pitfalls in Diagnosis and Treatment of Group A Streptococcal Infection
Dr. Michael Smith (Host): Welcome to Transformational Pediatrics. I’m Dr. Michael Smith and our topic is, “The Five Most Common Pitfalls in Diagnosis and Treatment of Group A Streptococcal Infection.” My guest is Dr. Angela Meyers. Dr. Meyers is Division Director of Infectious Diseases, Pediatric Infectious Diseases, Fellowship Program Director, and Medical Director of Travel Medicine with Children’s Mercy Kansas City. Dr. Meyers, welcome to the show.
Dr. Angela Meyers (Guest): Thank you, Dr. Mike.
Dr. Smith: In the title, we have five common pitfalls and you list the first pitfall as testing young children. Why is that a pitfall?
Dr. Meyers: It is a pitfall for several reasons. Most importantly young children rarely get strep throat. A child younger than three years of age who has an older sibling with strep throat and who has symptoms compatible with strep throat may, in fact, have strep throat. But, the majority of toddlers who have a sore throat have a viral cause for their sore throat. When you test them and they have a positive result, the likelihood is that result is actually colonization showing up. Additionally, rheumatic fever is very rare in the young child which is the reason why we treat strep throat.
Dr. Smith: With testing the young child, that could lead to, obviously, overtreatment or mistreatment. As you mentioned, in most cases, it’s a viral syndrome. Let’s move onto pitfall number two. You say that is testing those with nonspecific signs and symptoms. Why is that a pitfall?
Dr. Meyers: It’s a pitfall because between 15 and 20% of children in the winter and spring months of the year are colonized with strep throat in their throat. Again, if you test a child who doesn’t have symptoms that are very specific for strep throat or they are consistent with strep throat, then the likelihood is if you have a positive result it represents colonization and not true infection. Like you mentioned before, then you are giving antibiotics unnecessarily.
Dr. Smith: When it comes to testing – I think we’ll get into this when we talk about an algorithm that you would like community offices to follow – when does testing become appropriate, then? What do you look for before you order those barrages of tests?
Dr. Meyers: That’s a really good question. In general, children typically have fever and they have sore throat. A child should not be tested if they do not have sore throat, which is often the case. In addition to the sore throat, they need to have a lack of viral symptoms meaning that they don’t have runny nose; they don’t have congestion; they don’t have prominent cough and they should have at least one physical exam finding consistent with strep throat. So, they should have a red throat or puss on the tonsils or tender cervical adenopathy that indicates that this patient likely has strep throat.
Dr. Smith: Let’s go on then to pitfall number three. You have that as testing those with viral respiratory tract symptoms. I think you kind of just hit on there a little bit, right? So, we have viral symptoms: runny nose, that dry hacky cough. Is that what we mean here? We see those kind of viral symptoms and we end up testing for strep and that leads us down the wrong path, right?
Dr. Meyers: Correct. It does lead us down the wrong path. Remember that even though strep throat is a common disease, it really only represents about 20% of all visits to primary care or to emergency rooms and urgent cares. It really is only about 20% of sore throat visits. So, the overwhelming majority are still going to be viral causes and that’s why it makes it so important not to test children who do not meet the criteria before testing them.
Dr. Smith: Pitfall number four: repeat testing or use of serologic testing in asymptomatic previously treated children. Why is that a pitfall?
Dr. Meyers: Well, oftentimes, if repeat testing shows a positive result, then it represents colonization and not typically failure, especially if the child is asymptomatic. In addition, we don’t want to test asymptomatic children, let’s say, of a sibling who has proven strep throat, which oftentimes happens. Again, that child may be colonized and testing would lead you down the wrong path thinking that you need to treat something that you do not.
Dr. Smith: After treatment, after the course of antibiotics in this case, if they are asymptomatic, it’s a following game, right? You are going to have them come back, you follow up. If they remain asymptomatic, you let it go.
Dr. Meyers: Correct.
Dr. Smith: Pitfall number five: treatment with an inappropriate antimicrobial agent. What do you mean by inappropriate?
Dr. Meyers: That’s a really good question. There never has been any resistance reported for streptococcus pyogenes or Group A strep against penicillin or amoxicillin. Those are the first line agents to use in the setting of strep throat. But, oftentimes, we see children who receive a different drug like cefdinir or cephalexin or even amoxiclav – amoxicillin clavulanate. Those are not first line drugs to treat strep throat. People sometimes suffer under the wrong impression that the Group A strep has become resistant which has not ever been seen. The other piece to this, which is a little complicated, is that oftentimes parents believe their child to be penicillin allergic. The true rate of penicillin allergy among the population in our country is about 1%. Most of the time, when somebody believes themselves to be penicillin allergic, they’re not. They received amoxicillin or penicillin at some point in time in the past and they had a rash with it and oftentimes, that rash really represented something viral and not actually an allergy to the medication. Careful history of what that rash was and what really happened, what were the events around the previous treatment, is really important to be able to tease out the people with true allergy versus those who just had a rash that was not really allergy related.
Dr. Smith: Right. This is interesting to me because we know how important the correct diagnosis is, the right drug at the right dose with the right patient. This seems to be a great education or re-education opportunity, right? I know Children’s Mercy is a large hospital. Children’s Mercy has a great influence on community doctors. Is there a plan to outreach to community doctors and re-educate about strep A, true resistance, etc.? Is that something you guys are looking at?
Dr. Meyers: I’m so glad you asked that. We have already done that. One of my trainees, who is a fellow in infectious diseases, her big project is working with three pediatric groups around town right now to improve their testing strategies and the treatment of children with strep throat. It’s wonderful. Practices have really welcomed us with open arms and they have been open to some minor suggested changes to just improve the already excellent care they are giving. We hope to see some improvements and some changes here in the next few months.
Dr. Smith: In that same process, are you teaching the community physicians, maybe, like an algorithm to follow when dealing with these types of symptoms in patients?
Dr. Meyers: Yes, in fact, we are. There are two good algorithms you can use. One is through the Infectious Disease Society of America. They have developed a clinical practice guideline for strep pharyngitis. The algorithm they use in that document is quite good. There is another one through the American Academy of Pediatrics. Dr. Jackson and I have recently developed an EQIPP module – which stands for Education in Quality Improvement for Pediatric Practices. That algorithm is actually quite easy to use and good for pediatricians to think about when they are diagnosing strep throat in their practices. That will be available soon through the AEP this coming month.
Dr. Smith: How open are you finding the community physicians to these algorithms? Are they open to these things? Are they putting them into practice? Are you seeing some of the outcome from your efforts?
Dr. Meyers: We haven’t seen the outcomes from the efforts yet but they have been very open to incorporating them into their practice and thinking of ways that will work for them. Every practice is a little bit different and I really encourage practices to think about that and how they can implement things like this within their own practice. A lot of it is that they want us to help provide them with tools to talk to parents to explain to the parent why a test may not be necessary even though they brought their child in for exactly that and what the dangers are in over testing.
Dr. Smith: One of the challenges in primary medicine, too, is patients come in and it’s almost like they’re expecting something to be done, they’re expecting a certain lab to be done, expecting a certain prescription to be written, and sometimes it’s just managing those patients and parents expectations, right?
Dr. Meyers: Exactly.
Dr. Smith: Dr. Meyers, thank you for all the work that you’re doing. It’s great work and I want to thank you for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy, Kansas City. For more information you can go to ChildrensMercy.org. I’m Dr. Michael Smith. Thanks for listening.
The Five Most Common Pitfalls in Diagnosis and Treatment of Group A Streptococcal Infection
Dr. Michael Smith (Host): Welcome to Transformational Pediatrics. I’m Dr. Michael Smith and our topic is, “The Five Most Common Pitfalls in Diagnosis and Treatment of Group A Streptococcal Infection.” My guest is Dr. Angela Meyers. Dr. Meyers is Division Director of Infectious Diseases, Pediatric Infectious Diseases, Fellowship Program Director, and Medical Director of Travel Medicine with Children’s Mercy Kansas City. Dr. Meyers, welcome to the show.
Dr. Angela Meyers (Guest): Thank you, Dr. Mike.
Dr. Smith: In the title, we have five common pitfalls and you list the first pitfall as testing young children. Why is that a pitfall?
Dr. Meyers: It is a pitfall for several reasons. Most importantly young children rarely get strep throat. A child younger than three years of age who has an older sibling with strep throat and who has symptoms compatible with strep throat may, in fact, have strep throat. But, the majority of toddlers who have a sore throat have a viral cause for their sore throat. When you test them and they have a positive result, the likelihood is that result is actually colonization showing up. Additionally, rheumatic fever is very rare in the young child which is the reason why we treat strep throat.
Dr. Smith: With testing the young child, that could lead to, obviously, overtreatment or mistreatment. As you mentioned, in most cases, it’s a viral syndrome. Let’s move onto pitfall number two. You say that is testing those with nonspecific signs and symptoms. Why is that a pitfall?
Dr. Meyers: It’s a pitfall because between 15 and 20% of children in the winter and spring months of the year are colonized with strep throat in their throat. Again, if you test a child who doesn’t have symptoms that are very specific for strep throat or they are consistent with strep throat, then the likelihood is if you have a positive result it represents colonization and not true infection. Like you mentioned before, then you are giving antibiotics unnecessarily.
Dr. Smith: When it comes to testing – I think we’ll get into this when we talk about an algorithm that you would like community offices to follow – when does testing become appropriate, then? What do you look for before you order those barrages of tests?
Dr. Meyers: That’s a really good question. In general, children typically have fever and they have sore throat. A child should not be tested if they do not have sore throat, which is often the case. In addition to the sore throat, they need to have a lack of viral symptoms meaning that they don’t have runny nose; they don’t have congestion; they don’t have prominent cough and they should have at least one physical exam finding consistent with strep throat. So, they should have a red throat or puss on the tonsils or tender cervical adenopathy that indicates that this patient likely has strep throat.
Dr. Smith: Let’s go on then to pitfall number three. You have that as testing those with viral respiratory tract symptoms. I think you kind of just hit on there a little bit, right? So, we have viral symptoms: runny nose, that dry hacky cough. Is that what we mean here? We see those kind of viral symptoms and we end up testing for strep and that leads us down the wrong path, right?
Dr. Meyers: Correct. It does lead us down the wrong path. Remember that even though strep throat is a common disease, it really only represents about 20% of all visits to primary care or to emergency rooms and urgent cares. It really is only about 20% of sore throat visits. So, the overwhelming majority are still going to be viral causes and that’s why it makes it so important not to test children who do not meet the criteria before testing them.
Dr. Smith: Pitfall number four: repeat testing or use of serologic testing in asymptomatic previously treated children. Why is that a pitfall?
Dr. Meyers: Well, oftentimes, if repeat testing shows a positive result, then it represents colonization and not typically failure, especially if the child is asymptomatic. In addition, we don’t want to test asymptomatic children, let’s say, of a sibling who has proven strep throat, which oftentimes happens. Again, that child may be colonized and testing would lead you down the wrong path thinking that you need to treat something that you do not.
Dr. Smith: After treatment, after the course of antibiotics in this case, if they are asymptomatic, it’s a following game, right? You are going to have them come back, you follow up. If they remain asymptomatic, you let it go.
Dr. Meyers: Correct.
Dr. Smith: Pitfall number five: treatment with an inappropriate antimicrobial agent. What do you mean by inappropriate?
Dr. Meyers: That’s a really good question. There never has been any resistance reported for streptococcus pyogenes or Group A strep against penicillin or amoxicillin. Those are the first line agents to use in the setting of strep throat. But, oftentimes, we see children who receive a different drug like cefdinir or cephalexin or even amoxiclav – amoxicillin clavulanate. Those are not first line drugs to treat strep throat. People sometimes suffer under the wrong impression that the Group A strep has become resistant which has not ever been seen. The other piece to this, which is a little complicated, is that oftentimes parents believe their child to be penicillin allergic. The true rate of penicillin allergy among the population in our country is about 1%. Most of the time, when somebody believes themselves to be penicillin allergic, they’re not. They received amoxicillin or penicillin at some point in time in the past and they had a rash with it and oftentimes, that rash really represented something viral and not actually an allergy to the medication. Careful history of what that rash was and what really happened, what were the events around the previous treatment, is really important to be able to tease out the people with true allergy versus those who just had a rash that was not really allergy related.
Dr. Smith: Right. This is interesting to me because we know how important the correct diagnosis is, the right drug at the right dose with the right patient. This seems to be a great education or re-education opportunity, right? I know Children’s Mercy is a large hospital. Children’s Mercy has a great influence on community doctors. Is there a plan to outreach to community doctors and re-educate about strep A, true resistance, etc.? Is that something you guys are looking at?
Dr. Meyers: I’m so glad you asked that. We have already done that. One of my trainees, who is a fellow in infectious diseases, her big project is working with three pediatric groups around town right now to improve their testing strategies and the treatment of children with strep throat. It’s wonderful. Practices have really welcomed us with open arms and they have been open to some minor suggested changes to just improve the already excellent care they are giving. We hope to see some improvements and some changes here in the next few months.
Dr. Smith: In that same process, are you teaching the community physicians, maybe, like an algorithm to follow when dealing with these types of symptoms in patients?
Dr. Meyers: Yes, in fact, we are. There are two good algorithms you can use. One is through the Infectious Disease Society of America. They have developed a clinical practice guideline for strep pharyngitis. The algorithm they use in that document is quite good. There is another one through the American Academy of Pediatrics. Dr. Jackson and I have recently developed an EQIPP module – which stands for Education in Quality Improvement for Pediatric Practices. That algorithm is actually quite easy to use and good for pediatricians to think about when they are diagnosing strep throat in their practices. That will be available soon through the AEP this coming month.
Dr. Smith: How open are you finding the community physicians to these algorithms? Are they open to these things? Are they putting them into practice? Are you seeing some of the outcome from your efforts?
Dr. Meyers: We haven’t seen the outcomes from the efforts yet but they have been very open to incorporating them into their practice and thinking of ways that will work for them. Every practice is a little bit different and I really encourage practices to think about that and how they can implement things like this within their own practice. A lot of it is that they want us to help provide them with tools to talk to parents to explain to the parent why a test may not be necessary even though they brought their child in for exactly that and what the dangers are in over testing.
Dr. Smith: One of the challenges in primary medicine, too, is patients come in and it’s almost like they’re expecting something to be done, they’re expecting a certain lab to be done, expecting a certain prescription to be written, and sometimes it’s just managing those patients and parents expectations, right?
Dr. Meyers: Exactly.
Dr. Smith: Dr. Meyers, thank you for all the work that you’re doing. It’s great work and I want to thank you for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy, Kansas City. For more information you can go to ChildrensMercy.org. I’m Dr. Michael Smith. Thanks for listening.