Strep throat is an infection of the tonsils caused by the bacteria Streptococcus pyogenes, also known as Group A Strep.
Symptoms
The most common symptoms are:
- Sore throat
- Fever
- Decreased appetite
- Headache
- Nausea/vomiting
- Sandpapery rash on torso and extremities (when this is present we refer to the illness as Scarlet Fever)
Common exam findings are:
- Swollen, red tonsils
- White spots on the tonsils (called exudates, representing pus on the tonsils)
- Small red dots on the hard palate (called palatal petechia)
- Swollen lymph nodes/glands under the chin
Interestingly, sometimes kids don’t have a sore throat at all but have some combination of rash/headache/nausea.
Importantly, the presence of symptoms such as cough and runny nose argues against the diagnosis of strep; these symptoms are more likely caused by a common cold virus that does not need antibiotics for treatment.
Diagnosis
If strep is suspected, we will do a swab of the tonsils to perform a rapid strep test. These results will be ready in about 6 minutes. If the rapid strep test is positive, we will start treatment. If the rapid strep test is negative, we send the swab for a back up throat culture. The throat culture takes ~48 hours to result. On the rare occasion, a throat culture will come back positive even if the rapid strep test was negative. If this happens, we will call you to start treatment.
Treatment
We treat strep throat for two reasons. The first being to help kids feel better faster. The second, and arguably more important reason, is to prevent long term complications from strep such as acute rheumatic fever (which is thankfully very rare!).
Strep requires antibiotics for treatment, most commonly either amoxicillin or cephalexin. Kids are considered no longer contagious after 12 hours on antibiotics, so most kids can go back to school the day after they start the antibiotics as long as they are fever free and feeling better.
In addition to antibiotics, pain control (with acetaminophen and/or ibuprofen) and a focus on hydration are crucial to managing the illness.
Recurrent strep
Some kids unfortunately end up getting many episodes of strep. We refer to ENT to consider removal of tonsils for kids who have:
- 7 episodes of strep within 1 year
- 5 episodes of strep per year for the last 2 years
- 3 episodes of strep per year for the last 3 years
What else should parents/patients know?
While strep may seem straight forward, there are some nuances that I think are interesting and may come up when we evaluate you or your child.
- The strep bacteria is universally sensitive to amoxicillin and cephalexin, our first line antibiotics. This means the antibiotics work. So if a child is getting recurrent infections, it is because they have had new exposures to strep from others, assuming the full course of antibiotic was taken.
- Strep throat is rare in children who are younger than 3 years old and complications like acute rheumatic fever are almost non-existent. Thus, unless we know the child has been exposed to strep, we do not usually test for strep in children under age 3.
- Strep colonization is a common phenomenon – this is when someone has the strep bacteria living on their tonsils but it is not causing any symptoms, it is just casually hanging out. Strep colonization is benign and does not require treatment in the vast majority of cases. This is why we don’t want to test for strep unless symptoms are indicative of strep throat – otherwise we could end up finding someone who has symptoms due to a virus but a positive strep test because they are a carrier, leading to unnecessary antibiotics.
- Unless strep is “ping-ponging” between multiple members of a household for many recurrent cases, there is no indication to test kids who have been exposed to strep but have no symptoms.