Streptococcus, questions and answers for treating children

Pandemic restrictions have protected us not only from Covid-19 but also from other infections. When normal activity resumed, respiratory viruses and bacteria circulated more than in the past in all age groups, including the pediatric one.

In particular, there has been an increase in infectious episodes caused by group A beta-haemolytic Streptococcus (SBEA). At the same time, both in Italy and in Europe, the production and distribution of the antibiotic most used in these cases, amoxicillin, has decreased. Starting from these premises, the technical table for infectious diseases and vaccinations of the Italian Society of Pediatrics, led by Professor Susanna Espositohas prepared a series of recommendations to encourage greater adherence to national guidelines for the appropriate use of antibiotics.

“The purpose of this document is to provide parents with some answers to the most common doubts regarding group A beta-haemolytic streptococcus. The main advice is to always contact the pediatrician to avoid inappropriate use of antibiotics and guarantee children the best pathways for the protection of their health on the basis of scientific evidence”, explains the president of SIP Anna Maria Staiano.

Here is a series of questions and answers that will help you deal with the problem

Is BEA (group A beta hemolytic streptococcus) always responsible for pharyngotonsillitis?
Pharyngotonsillitis is a common pathology in childhood, mainly of viral origin. SBEA is responsible for about 1 in 4 cases of pharyngotonsillitis and mainly affects school children and adolescents, with a prevalence ranging from 19% to 30% between 5 and 19 years. The BEA that causes strep throat is the same that causes scarlet fever; this occurs when SBEA produces certain substances called exotoxins.

What are the complications of SBEA pharyngotonsillitis?
SBEA pharyngotonsillitis has a benign course, with resolution of the picture within 3-7 days. However, in a minority of cases, streptococcal infection can be associated with complications resulting from an extension of the infection into nearby tissues, such as peritonsillar, parapharyngeal or retropharyngeal abscesses, otitis media, sinusitis, mastoiditis. There are also other complications such as rheumatic disease and acute post-streptococcal glomerulonephritis.

Is the throat swab always reliable?
The reliability of the throat swab depends on the adequacy of the collection of the sample which must be taken from the posterior wall of the oropharynx and from the surface of both tonsils, by adequately trained healthcare personnel. Contact with other areas of the oral cavity and with saliva must be avoided, also for this reason the use of the tongue depressor is essential. The collected sample can be analyzed by rapid antigen test, culture test or molecular tests.

Are rapid tests sufficient for the diagnosis or do other tests need to be done?
A positive or negative rapid antigen test result is sufficient for the diagnosis in most cases, without the need to perform a confirmatory culture test, unless there is a strong discordance with the clinical picture. Blood tests (antistreptolysin levels, C-reactive protein, and WBC counts) are not recommended for the diagnosis of SBEA pharyngotonsillitis or scarlet fever; the diagnosis of the latter is clinical in the presence of a positive throat swab for BEA.

When should a swab be done?
The execution of the swab must take place on the indication of the pediatrician to avoid erroneous diagnoses and inappropriate use of antibiotic therapy.

Should those who test positive for the swab always undergo antibiotic therapy?
A percentage of children, from 10 to 25%, who test positive for the swab are actually carriers of BEA. Carrier status can last from weeks to months, but is associated with minimal risk of complications and low risk of transmission. Antibiotic treatment is not recommended in subjects with BEA. Rapid tests and other microbiological tests cannot distinguish a person with BEA pharyngitis from a carrier of BEA who has intercurrent pharyngitis caused by another infectious agent. For this reason, in the absence of acute symptoms, or at the end of antibiotic therapy, the rapid test for the identification of BEA in the pharynx should not be performed.

In which cases is antibiotic therapy recommended?
In pediatric patients suffering from SBEA pharyngotonsillitis or scarlet fever, antibiotic therapy is recommended for the rapid reduction of symptoms and to avoid the risk of complications. If the pharyngotonsillitis is not due to BEA, antibiotic therapy is not recommended. The recommended antibiotic of first choice is amoxicillin. In the absence of other indications (relapses, therapeutic failure) or in the absence of contraindications to amoxicillin, antibiotic therapy with amoxicillin-clavulanic acid, cephalosporins or macrolides is not recommended.

What to do if my child is allergic to amoxicillin?
In case of allergy, suspected or confirmed, one can opt for macrolides (in particular, azithromycin at a dose of 20 mg/kg/day for 3 days in once-daily administration to overcome the resistance of SBEA to macrolides). 2nd and 3rd generation cephalosporins should not be recommended.

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What to do if my child has recurrent SBEA pharyngitis after antibiotic treatment?
At present, on the basis of the evidence available in the literature, it is not possible to establish a recommendation regarding the antibiotic therapy of recurrent pharyngotonsillitis from SBEA after treatment with amoxicillin. Only in cases where tonsillectomy is planned could alternative amoxicillin-clavulanic acid or clindamycin therapy be attempted.

When can the child go back to school?
Resuming school in the case of streptococcal pharyngotonsillitis or scarlet fever can take place at least 24 hours after the start of antibiotic therapy and does not require a medical certificate or documentation of the negative swab.

What are the preventive measures?
Important measures to prevent the transmission and spread of SBEA infections are adequate hand hygiene, adequate ventilation of internal environments and the elimination of possible promiscuous behaviors (for example, sharing utensils, glasses and personal items, etc.).

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