Unit 1_Acute Tonsilopharyngitis.pptx

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1. Unit 1: Diagnosis and Management of Tonsilo-pharyngitis 1

2. Learning Objectives Describe the characteristics of Group A Beta Hemolytic Streptococci Describe the epidemiology of GABHS tonsilopharyngitis Explain the difference between viral and GABHS tonsilopharyngitis Outline the diagnostic modality of GABHS tonsilo-pharyngitis Outline the management of GABHS tonsilopharyngitis Explain methods of prevention of tonsilopharyngitis 2

3. Introduction Rheumatic fever is an inflammatory disease involving the joints, skin, heart and brain, which develops following an untreated or partially treated group A b- haemolytic streptococcal (GAS) infection of the throat (streptococcal pharyngitis ). Up to 30% of sore throats in children and young people are caused by GAS, and 0.3% to 3% of young people with an untreated GAS sore throat will develop RF. After recovery from the initial episode of RF, up to 60% to 65% of patients develop valvular heart disease and the risk of RF recurrence following GAS infection rises to 50%. Identification and treatment of bacterial sore throat is an important component of Rheuamtic Fever/Rheumatic Heart Disease Prevention and Control Program

4. Tonsilopharyngitis Sore throat( Tonsilopharyngitis ) is a symptom caused by inflammation of pharynx, tonsils or other surrounding structures Viral sorethroat is the predominate cause Group A beta hemolytic Streptococci is commonest bacterial cause 20-40% in children 5-15% of sore throat clinic visits in adults 4

5. Group A Beta Hemolytic Streptococci (GABHS) 5 Gram-positive, nonmotile, non–spore-forming cocci 0.5-1.2µm in size. in pairs or chains They are negative for oxidase and catalase. Characterized by local invasion and release of extracellular toxins and proteases

6. Group A Beta Hemolytic Streptococci … This organism may cause suppurative disease, such as pharyngitis , impetigo, cellulitis , myositis , pneumonia, and puerperal sepsis. It also may be associated with nonsuppurative disease, such as rheumatic fever and Acute Poststreptococcal Glomerulonephritis . Group A streptococci elaborate the cytolytic toxins Streptolysins S and O. Of these, streptolysin O induces persistently high antibody titers that provide a useful marker of group A streptococcal infection and its nonsuppurative complications M protein fragments of certain serotypes of GABHS are similar to heart muscle Antibodies produced against the bacteria Antigens are affect the tissue and linked to development heart valve damage. 6

7. EPIDEMIOLOGY of GABHS Humans are exposed to GABHS in the environment Humans are the natural reservoir for GABHS Mostly spread through droplets of salivary or nasal secretions Overcrowding , poverty, and close contact with person with streptococcal sore throat are considered risk factors for transmission The incubation period is 2 to 5 days Throat and skin are common sites of GABHS infection 7

8. EPIDEMIOLOGY of GABHS… GABHS infections usually resolve without treatment however if left u untreated it can lead to acute rheumatic fever in some people. Antibiotic treatment decreases severity of symptoms and reduces the risk of transmission to others after 24 hrs of treatment Treatment also decreases the risk of acute rheumatic fever Studies show that ARF associated with GABHS pharyngitis can be prevented if treatment is commenced within 9 days of symptoms appearing. 8

9. Clinical Presentations of Sore Throat 4-1 . GABHS pharyngitis 4-2. Viral Pharyngitis 9

10. 4-1.GABHS PHARYNGITIS Sudden onset of sore throat Pain on swallowing and Fever above 38 C Headache, nausea, vomiting and abdominal pain Tonsilopharyngeal erythema Enlarged tonsils with exudate Tender and enlarged anterior cervical lymph nodes ( lymphadenitis) 10

11. 4.2 VIRAL PHARYNGITIS Cough , runny nose conjunctivitis Hoarseness, coryza Anterior stomatitis, discrete intra-oral ulcerative lesions Exanthema, ,diarrhea Absence of fever (strongly suggest ) 11

12. Bacterial Vs Viral Pharyngitis

13. DIAGNOSIS OF BACTERIAL SORE THROAT The diagnosis of streptococcal pharyngitis (GABHS) can either be clinical only or using clinical criteria supported by laboratory investigations. The gold standard diagnostic method is by using a Clinical Prediction rule (CPR) supported by rapid antigen test (RAT) and/or throat culture. 13

14. THROAT CULTURE Not available in all set ups Delay in getting results at least 48 hrs. Technical errors ( impact on the results) Cost of test is high Many people are asymptomatic carriers (10% of school age children). 14

15. Rapid Antigen Detection Test for GABHS Not available Not validated in Ethiopia Expensive 15

16. ASO Titer: NO role in Acute Tonsilopharyngitis 16

17. GABHS Diagnosis Clinical Decision Rules (CDR) Cardinal Clinical features Symptoms or Signs Points History of high fever or (objective record ≥ 38 o C) 1 Absence of cough and rhinorrhea 1 Tender anterior Cervical adenopathy 1 Tonsillar swelling or exudates 1 Clinical Decision Rule (CDR) ≥ 2 points, treat as GAβHS pharyngitis (with antibiotic) , < 2 points, treat as viral pharyngitis (no antibiotic 17

18. Management of Tonsilo-pharyngitis Relief of acute symptoms Prevention of suppurative and non suppurative complications Reduce communicability Pain and fever management ( Paracetamol) 18

19. Antibiotics for GABHS Treatment First Line: Benzathine penicillin ( First Line ) Dose: Wt . < 30kg:600,000 IU stat. Wt . > 30 kg:1.2 million IU IM stat. Use Safe BPG Injection Procedures! Alternative Amoxicillin Dose : Children < 7years: 50 mg/kg per day in three divided doses for 10 days. Age>7Years: 500mg PO TID for 10 Days 19

20. Antibiotics for GABHS Treatment… If Patient allergic to penicillin: ERYTHROMYCIN Dose Less than 7 years: 250 mg BD for 10 days More than 7 years: 500 mg BD for 10 days 20

21. Why Benzathine Penicillin? Single injection Better bactericidal effect than oral Oral treatment needs 10 whole days to be effective Oral macrolides : clinical improvement but no eradication of organism. Cost effective, evidence based. Parents and patients more satisfied.

22. Is it cost-effective to administer BPG for all cases of suspected strep sore throat? An overall protective effect for the use of penicillin against acute rheumatic fever of 80% with an NNT of 60 children per year to prevent 1 episode of rheumatic fever. Mild hypertension: have to treat 800 people per year to prevent 1 episode of stroke The estimated cost of preventing one case of rheumatic fever by a single monthly intramuscular injection of penicillin is US$46 Valve replacement surgery for 1 case of RHD is at least US$15, 000 Cardiac surgery only available in S Africa, Ghana and Egypt

23. Prevention and Health Education Families should be educated about: 1.The symptoms of GAS pharyngitis . 2 The serious consequences of untreated pharyngitis i.e. ARF and RHD and the need to consult medical personnel as early as possible to avoid complications. 3 The need to avoid pharyngitis by improving house ventilation and hygiene and avoid crowding. 4. Importance of adherence to a 10 days course of antibiotics in oral treatment.

24. Case study W/O Almaz brought her five years old girl Helen to the outpatient clinic with acute onset of fever, severe throat, pain exacerbated by swallowing, headache and abdominal pain. No runny nose, no cough. Physical examination : Wt. 20 kg, her temperature was 38.30C axillary, the tonsils were symmetrically enlarged, red with exudates. She had multiple enlarged painful anterior neck lymphadenopathies. No other abnormal findings detected. 24

25. Questions . What is your clinical diagnosis of Helens’ illness ? What tests do you need to reach at a diagnosis ? What is the most likely causative organism of her illness? How would you like to treat Helen? Which of the clinical presentation helps you to decide about the treatment you are going to give? What is the drug of choice (type, dose and route of administration)? What other additional Advice do you like to give to W/O Almaz? 25

26. Key points Group A beta hemolytic streptococcus is one of the commonest cause of bacterial tonsilo-pharyngitis . Diagnosis should be suspected early and use clinical decision rule. Drug of choice for GABHS is single injection of Benzathine Penicillin G. Families should be educated about identifying children with sore throat early and contacting health care workers for 26

27. End of Unit 1 27