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Modern EM: Case 1 and 2 - Strep Throat

Posted Mar 26 2012 12:00am
A sister and brother, aged 7 and 14, respectively present with pharyngitis.  The 7F has sore throat, cough, fever, and post-tussive vomiting for 1 day.  She has posterior pharyngeal erythema, no LAD, no exudate, no petechiae, and looks like a viral URI.

The 14M had culture confirmed GAS pharyngitis 3 weeks ago, was treated with PCN-VK and symptoms resolved.  Now, he's in the ED with signs and symptoms of pharyngitis again, including dysphagia, fever, cough, posterior pharyngeal erythema, swollen tonsils, and petechiae on his hard palate.

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I ordered cultures on each of them and then I opened up MDCalc (I have shortcuts saved to all my devices' desktops) to the Modified Centor Score for Strep Pharyngitis.  The easy-to-use calculator tells me that I won't treat the 7F unless positive cultures come back, and the 14M will get empirically covered.

But what antibiotic do I give him?  It seems that he failed PCN-VK.  Traditionally, many have reached for azithromycin next but I had just read a plea by Dr. Ryan Radecki on his blog EM Literature of Note to stop using macrolides for strep throat based on a study out of Rush that reported cases of rheumatic fever secondary to macrolide resistance.  The paper also notes as high as a 15% US single center resistance rates.

If not a z-pack, then what?  I opened the EMRA Abx guide which recommended cephalexin or clindamycin.  I chose cephalexin, rechecked in Micromedix the indications and dosing, and felt confident I had made the right choice.  I also noted to myself that if in the future I were treating a child with a history of PCN anaphylaxis, then clindamycin would be my choice.


I went home that night, read the paper and tweeted Ryan.  He and Dr. Graham Walker (MD Calc) were already having a conversation about the issue and I asked them what their second line choice of antibiotic is?


Finally, I went on my favorite quick reference resource WikEM .  Their entry on strep pharyngitis was recommending azithromycin as the second line drug.  I updated the site, and referenced the article.


This is a 3-part guest series by Dr. Timothy Peck, who is launching his own blog at ModernEM.blogspot.com . Check it out!
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