Strep Throat—To Fear or Not to Fear (Again)?

The news of an invasive streptococcal infection, presenting as streptococcal toxic shock syndrome in an otherwise healthy adult, has made national headlines again in recent weeks.^1,2 Widespread interest in and concern over strep throat infections has emerged as this case reminds us how the same bacteria responsible for strep throat, Group A Streptococcus, can lead to more serious and often fatal complications including septic shock and multi-organ failure. However, this is not the first, and certainly will not be the last time, that group A streptococcal infections have captured the public’s attention. Since at least the 1980s, there has been increasing recognition in both the medical community and general public of invasive group A streptococcal infections, although epidemics attributed to this bacterial group have been described throughout history.³

Group A streptococcal infections can cause a wide spectrum of disease. At one end are the more common presentations including pharyngitis (ie, strep throat), skin or soft tissue infections, ear infections, and sinusitis, which are often self-limited or easily treated with a course of antibiotics.^3,4 Severe manifestations of streptococcal infection fall at the other end of the spectrum and represent rare complications associated with substantial morbidity or mortality. Examples include necrotizing fasciitis (a rapidly progressive and destructive skin/soft tissue infection), bacteremia (bloodstream infection), meningitis (infection of lining of the brain) or brain abscess, and streptococcal toxic shock syndrome (shock with multi-organ failure).^3,5

Early diagnosis and prompt treatment of streptococcal infection can go a long in helping reduce sequelae of disease. Risk factors for community-acquired, invasive streptococcal infection have been identified and may help physicians more promptly recognize a serious case. These include the presence of chronic diseases, such as HIV infection, diabetes, malignancy, and heart disease, the use of immunosuppressive drugs, or intravenous drug use. Environmental factors that may predispose to streptococcal infections include large household size and presence of a child with sore throat, which emphasize the risk of person-to-person transmission of group A streptococcus.⁶

Strep throat usually presents with an abrupt onset of sore throat and can be accompanied by fever, abdominal pain, decreased appetite, swollen tonsils and lymph nodes, and a widespread rash. Children who develop symptoms for strep throat should see their pediatrician early on and have diagnostic tests performed, with appropriate antibiotic treatment given if test results confirm a diagnosis of strep throat. Early diagnosis and treatment of strep throat will reduce the risk of complications in children and help prevent potential transmission to parents, household contacts, or others.⁷

In adults, strep throat is often considered a self-limited nuisance that usually resolves over time, but antibiotic treatment may help reduce the risk of more serious complications. Fortunately, for now, group A streptococci remain exquisitely sensitive to the beta-lactam class of antibiotics and can be treated effectively with penicillin or one of its close cousins.⁸

What can be done to reduce our personal risk of strep infection? To date, there are no data to support giving antibiotics prophylactically to household members or others who have come into contact with someone with strep throat. Instead, hand washing is the single most important intervention that all of us can do to help reduce the spread of group A streptococcus, as well as other pathogens.

Charitha Gowda, MD, MPH, MSCE, is a pediatric infectious diseases expert physician in the Department of Pediatrics at Nationwide Children’s Hospital and an Assistant Professor, Infectious Diseases, Ohio State University College of Medicine, both in Columbus, Ohio. She is also a member of the Editorial Advisory Board for Contagion®.

References

1. Gatewood, J. “Dad’s case of strep throat leads to amputations.” CNN.com, Updated 16 March 2017. Available at http://www.cnn.com/2017/03/16/health/strep-throat-amputation-septic-shock-michigan-bn/. Accessed on 20 Match 2017.
2. Holley, P. “A father went to the hospital with stomach pain. He left without his hands and feet.” The Washington Post. March 18, 2017. Available at https://www.washingtonpost.com/news/to-your-health/wp/2017/03/18/a-father-went-to-the-hospital-with-stomach-pain-he-left-without-his-hands-and-feet/?utm_term=.add181e62331. Accessed on 20 March 2017
3. Stevens DL. Streptococcal Toxic-Shock Syndrome: Spectrum of Disease, Pathogenesis, and New Concepts in Treatment. Emerging Infectious Diseases. 1995;1(3):69-78. doi:10.3201/eid0103.950301.
4. Bisno AL, Stevens Dl. Streptococcal infections of skin and soft tissues. N. Engl J Med 1996;334:240.
5. Stevens, DL et al. Invasive group A streptococcal infections associated with a toxic shock-like syndrome and scarlet fever toxin A. N Engl J Med 1989;321(1):1-7.
6. Factor SH, Levine OS, Schwartz B, et al. Invasive Group A Streptococcal Disease: Risk Factors for Adults. Emerging Infectious Diseases. 2003;9(8):970-977. doi:10.3201/eid0908.020745.
7. American Academy of Pediatrics. Group A streptococcal infections. In: Red Book: 2015 Report of the Committee on Infectious Diseases, 30th, Kimberlin DW, Brady MT, Jackson MA, Long SS. (Eds), American Academy of Pediatrics, Elk Grove Village, IL 2015. p.732.
8. Wessels Mr. Clinical practice. Streptococcal pharyngitis. N Engl J Med 2011;364:648.