An 8-year-old boy is brought to the physician for sore throat and fever that began yesterday. He has no rhinorrhea, congestion, cough, or facial pain but has been complaining of abdominal pain. He took acetaminophen with no relief of throat or abdominal pain. The boy's past medical history is significant for 2 episodes of otitis media during infancy. He has no medication allergies. Physical examination shows enlarged tonsils with exudates and tender anterior cervical lymphadenopathy. The rapid antigen test for Streptococcus pyogenes is positive. Which of the following is the appropriate duration and rationale for treatment for this patient?

Question

An 8-year-old boy is brought to the physician for sore throat and fever that began yesterday.  He has no rhinorrhea, congestion, cough, or facial pain but has been complaining of abdominal pain.  He took acetaminophen with no relief of throat or abdominal pain.  The boy's past medical history is significant for 2 episodes of otitis media during infancy.  He has no medication allergies.  Physical examination shows enlarged tonsils with exudates and tender anterior cervical lymphadenopathy.  The rapid antigen test for Streptococcus pyogenes is positive.  Which of the following is the appropriate duration and rationale for treatment for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfbe_1a50_8f63_0d2c29804618_MD0005_00 Group A streptococcal pharyngitis is the most common bacterial pharyngitis in children and typically occurs at age 5-15. It presents with an abrupt onset of fever, sore throat, and malaise in the absence of upper respiratory symptoms (eg, cough, rhinorrhea, congestion). Classic physical examination findings include tonsillar exudates, tender anterior cervical lymphadenopathy, and palatal petechiae. Diagnosis should be confirmed with throat culture (preferred) or rapid antigen testing prior to initiation of antibiotics. Penicillin is the treatment of choice for streptococcal pharyngitis, as Streptococcus pyogenes remains very sensitive to penicillin. The benefits of antibiotic therapy include: Decreased symptom severity and duration Prevention of spread to close contacts Prevention of suppurative complications (eg, peritonsillar abscess, cervical lymphadenitis) Prevention of acute rheumatic fever Optimal duration of oral penicillin is 10 days both to ensure full eradication of bacterial carriage and to prevent rheumatic fever. Daily long-term prophylactic antibiotics are indicated for patients with a history of rheumatic fever to prevent recurrence of the disease. (Choice A) A 5-day course of oral penicillin is too short a duration to completely eradicate Group A streptococcus from the oropharynx and prevent acute rheumatic fever. On the other hand, a single dose of intramuscular penicillin is bactericidal for up to a month and can be given to patients who cannot tolerate oral antibiotics. A 5-day course of azithromycin is acceptable alternate therapy for penicillin-allergic patients. (Choices B and D) Post-streptococcal glomerulonephritis typically occurs 1-3 weeks after either a cutaneous or pharyngeal streptococcal infection. Antibiotics are effective for primary prevention of rheumatic fever, but their role in the prevention of post-streptococcal glomerulonephritis is unclear. (Choice E) Antibiotics minimize contagiousness within a day of initiating therapy, but they are continued for 10 days to prevent suppurative and nonsuppurative complications. Educational objective: The benefits of a 10-day course of penicillin for streptococcal pharyngitis include decreased symptom severity and duration, prevention of spread to close contacts, and prevention of acute rheumatic fever. References: Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. (http://www.ncbi.nlm.nih.gov/pubmed/19246689) Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/22048053) Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 Update by the Infectious Diseases Society of America. (http://www.ncbi.nlm.nih.gov/pubmed/22965026)

An 8-Year-Old Boy Is Brought to the Physician for Sore