Pediatric Annals

The Resident's Column

Carolyn T Spencer, MD

Abstract

The importance of group A streptococci (GABHS) as a cause of significant morbidity and mortality is often understated and underemphasized. To the parent, nurse, and frequently the physician, this infection is equated with "strep throat" and occasionally impetigo. The possibility of group A streptococcal pharyngitis is a reason that parents (and schools) frequently request antibiotics, and this request is often granted by physicians without an attempt to confirm that GABHS is indeed the pathogen causing the illness. However, as illustrated in this issue of Pediatrìe Annaís, not only should confirmation of a GABHS infection be the standard of care, but awareness and timely recognition of complications and signs of invasive disease is a must.

During my residency I have encountered nearly as many ways to diagnose and treat pharyngitis as I have physicians who were treating pharyngitis. Many physicians site their "clinical judgment" and the "cost factor" as reasons not to use rapid antigen detection tests or cultures to diagnose GABHS pharyngitis. However, Dr. Gerber's article (pp 269-273) underlines how unreliable our clinical judgment is in this particular instance, and we should not base treatment decisions strictly on our physical examination. Even the clinical gold standard for streptococcal pharyngitis, palatal petechiae, is not specific enough to determine the etiology of an infection.

It is quite surprising that many physicians do not follow recommended guidelines with regard to the diagnosis of GABHS pharyngitis. Therefore, as residents and future practitioners, we must take it upon ourselves to practice good, accurate medicine and to use the tools that we have available. There is morbidity and significant financial cost associated with using antibiotics when not necessary. It also gives the wrong impression to patients, parents, and schools regarding appropriate antibiotic use and what should be expected when they come to the pediatrician's office.

Another issue of group A streptococcal disease that we must address is that of thinking of GABHS as a pathogen beyond pharyngitis and impetigo. As Drs. Ayoub and Ahmed point out (pp 287-292), GABHS may cause infection at many other sites, including septic arthritis, mastoiditis, and pneumonia. One of the first pediatrie patients that I saw as a third year medical student was a previously healthy 11 -year-old boy who presented with fever, toxicity, pneumonia, and a faint rash in his groin area and who was mildly hypotensive. The attending (a private physician in the community) felt strongly that this clinical picture was consistent with invasive GABHS, and she treated the patient with clindamycin from the beginning. She was right, but it wasn't until much later that I realized how impressive her diagnostic skills were.

To the residents of tomorrow, group A streptococcus may be the Haemophilus influenzas type B of today. The possibility of developing a vaccine for GABHS looks hopeful. However, the multiple serotypes and complexities of the proteins involved make this an arduous task. Until this vaccine can be developed and becomes available, we must continue to be judicious in our management of group A streptococcal disease.

aCONCLUSIONS

Invasive GABHS can be the cause of significant morbidity and mortality in the pediatrie population, and we must recognize it as a significant pathogen. We must therefore strive to diagnose and treat group A streptococcal disease properly and be prepared to recognize it as a cause of invasive disease and not merely pharyngitis and impetigo.…

The importance of group A streptococci (GABHS) as a cause of significant morbidity and mortality is often understated and underemphasized. To the parent, nurse, and frequently the physician, this infection is equated with "strep throat" and occasionally impetigo. The possibility of group A streptococcal pharyngitis is a reason that parents (and schools) frequently request antibiotics, and this request is often granted by physicians without an attempt to confirm that GABHS is indeed the pathogen causing the illness. However, as illustrated in this issue of Pediatrìe Annaís, not only should confirmation of a GABHS infection be the standard of care, but awareness and timely recognition of complications and signs of invasive disease is a must.

During my residency I have encountered nearly as many ways to diagnose and treat pharyngitis as I have physicians who were treating pharyngitis. Many physicians site their "clinical judgment" and the "cost factor" as reasons not to use rapid antigen detection tests or cultures to diagnose GABHS pharyngitis. However, Dr. Gerber's article (pp 269-273) underlines how unreliable our clinical judgment is in this particular instance, and we should not base treatment decisions strictly on our physical examination. Even the clinical gold standard for streptococcal pharyngitis, palatal petechiae, is not specific enough to determine the etiology of an infection.

It is quite surprising that many physicians do not follow recommended guidelines with regard to the diagnosis of GABHS pharyngitis. Therefore, as residents and future practitioners, we must take it upon ourselves to practice good, accurate medicine and to use the tools that we have available. There is morbidity and significant financial cost associated with using antibiotics when not necessary. It also gives the wrong impression to patients, parents, and schools regarding appropriate antibiotic use and what should be expected when they come to the pediatrician's office.

Another issue of group A streptococcal disease that we must address is that of thinking of GABHS as a pathogen beyond pharyngitis and impetigo. As Drs. Ayoub and Ahmed point out (pp 287-292), GABHS may cause infection at many other sites, including septic arthritis, mastoiditis, and pneumonia. One of the first pediatrie patients that I saw as a third year medical student was a previously healthy 11 -year-old boy who presented with fever, toxicity, pneumonia, and a faint rash in his groin area and who was mildly hypotensive. The attending (a private physician in the community) felt strongly that this clinical picture was consistent with invasive GABHS, and she treated the patient with clindamycin from the beginning. She was right, but it wasn't until much later that I realized how impressive her diagnostic skills were.

To the residents of tomorrow, group A streptococcus may be the Haemophilus influenzas type B of today. The possibility of developing a vaccine for GABHS looks hopeful. However, the multiple serotypes and complexities of the proteins involved make this an arduous task. Until this vaccine can be developed and becomes available, we must continue to be judicious in our management of group A streptococcal disease.

aCONCLUSIONS

Invasive GABHS can be the cause of significant morbidity and mortality in the pediatrie population, and we must recognize it as a significant pathogen. We must therefore strive to diagnose and treat group A streptococcal disease properly and be prepared to recognize it as a cause of invasive disease and not merely pharyngitis and impetigo.

10.3928/0090-4481-19980501-11

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