Strep Throat (Streptococcal Pharyngitis)

Strep Throat (Streptococcal Pharyngitis)

What is strep throat?

An infection is most often caused by group A Streptococcus bacteria or GAS (streptococcus pyogenes or beta-haemolytic streptococcus / GABS), hence the name strep throat, resulting in inflammation and swelling, scratchiness and pain in the mucous membranes which line the back of the throat (pharynx), and sometimes the tonsils (adenoids). Groups C and G bacteria are also known to cause strep throat.

Once the bacteria enter the body it infects the pharyngeal tissue, resulting in an localised inflammatory reaction. These bacterial organisms can exist in the throat or on the surface of the skin and not display any symptoms. Thus, a person can carry the bacteria, but remain asymptomatic.

Strep throat is a common bacterial infection in children (especially those between the ages of 5 and 15), but can occur in adults of any age too. The majority of strep infections typically occur in the cooler months of the year (late autumn or fall and early springtime).

A strep infection requires medical intervention so as to prevent an array of complications such as rheumatic fever or inflammation of the kidneys, as well as rash or damage to the heart valves.

Is strep throat contagious?

Strep throat is a contagious infection and can be passed between people through breath, coughing and sneezing. Bacteria exists in bodily fluids, making transmission fairly straightforward and simple. Tiny droplets of saliva or nasal secretions that become airborne in close contact with another person can infect them with the bacteria, through inhalation. Transmission can also occur through the sharing of food or beverages or via contact with surfaces that have been touched by an infected individual and then touching one’s mouth, nose or eyes.

Transmission is thus more commonly seen in instances where individuals are in close proximity to one another, such as enclosed environments (schools, day care centres, shared home environments and the workplace).

Signs and symptoms of strep throat

Little girl experiencing a sore throat.Strep throat is not a life-threatening infection, but it can lead to other health complications if not sufficiently treated. Severity of an infection varies from one person to the next. The primary symptom of a sore or painful throat may or may not be accompanied by other signs of infection.

Normally symptoms of strep throat will develop within 2 to 5 days following exposure to the bacteria (this is known as the incubation period). An infection can clear on its own without treatment (typically within 3 to 7 days).

The most common symptoms of strep throat are:

  • Tenderness / soreness in the throat (with red and white patches or streaks of pus, and swollen tonsils – this can lead to bad breath)
  • Small red, white or yellow spots at the back of the mouth (near the roof of the mouth, or on the soft or hard palate)
  • Fever (sudden and often around 101˚F or 38˚C or higher)
  • Chills and / or body aches
  • Swollen lymph nodes (on the sides of the upper portion of the neck)
  • Difficulties with swallowing / pain when swallowing
  • Headache
  • Loss of appetite
  • Rash (which can spread to the neck or chest, and eventually the entire body) *this is normally associated with scarlet fever
  • Nausea and / or vomiting
  • Dehydration (due to a lack of fluid intake) – in varying degrees
  • General malaise (feeling unwell)

A person infected with strep throat may be contagious for between 2 and 3 weeks even if symptoms have cleared. Taking antibiotics can reduce this within 24 hours of the first dose, as well as help to prevent the infection from worsening.

How symptoms of strep throat can affect different age groups

  • Infants: Infection in young babies is not common. When an infection does occur, babies typically are reluctant to feed and display bouts of irritability and fussiness. A baby may also experience a nasal discharge and low-grade fever.
  • Young children: Along with a sore throat and pain when swallowing, young children may also experience loss of appetite and abdominal pain.
  • Older children and adolescents: As children grow older, strep throat infections can become more uncomfortable. Throat pain is often severe, and accompanied by a high fever (typical of a bacterial infection).
  • Adults: Symptoms are generally mild, but can be severe in some cases.

How to tell the difference between tonsillitis and strep throat

Tonsillitis is generally caused by both viral and bacterial infections. Viruses which can cause tonsillitis as a symptom include influenza (flu), herpes-simplex virus, HIV, coronavirus, Epstein-Barr virus or adenovirus.

The most common bacteria to cause tonsillitis is the same group A Streptococcus which results in strep throat. Other species of strep bacteria, such as chlamydia pneumoniae (chlamydia), Neisseria gonorrhoeae (gonorrhoea) and staphylococcus aureus can also lead to the development of tonsillitis. Strep throat, however, is not caused by any other group of bacteria.

The two conditions may display similar symptoms. Symptoms of tonsillitis other than those similar to strep throat include:

  • High fever (higher than in the case of strep throat -102.6°F or 39.2°C, or higher)
  • Stiff neck
  • Upset stomach
  • Discolouration on or around the tonsils (white or yellow)

When to call the doctor

When a sore throat …

  • Lingers for 2 days (48 hours) or more
  • Is accompanied by white patches or streaks on the back of the throat
  • Is accompanied by dark or red spots on the palate of the mouth or tonsils
  • Is accompanied by a pink rash on the skin that feels like fine sandpaper
  • Is accompanied by a high fever lasting longer than 2 days (48 hours)
  • Results in difficulties with swallowing
  • Has not shown improvement within 48 hours of being diagnosed and treated with antibiotics

If a strep throat infection has been diagnosed and treated, and symptoms don’t appear to clear within 1 to 2 weeks, a doctor may wish to check for signs of rheumatic fever. Symptoms associated with this condition include body weakness, joint pain, a raised red rash, lumps beneath the skin, shortness of breath and uncontrolled jerking movements (the limbs).


If a sore throat is ever accompanied by the below symptoms, immediate medical care is required:

  • Difficulties with breathing (with or without audible noises)
  • Inability to swallow any amount of food and liquids, or saliva
  • Inability to open the mouth
  • Throat pain which is severe and accompanied by swelling or redness around the neck area
  • Bleeding in the throat

When a sore throat is not likely strep throat

The general rule of thumb is that the more cold-like symptoms are present, such as a congested nose, sneezing or coughing, the more likely it is that a sore throat is as a result of a viral infection (not a bacterial one).

Any instance of a sore throat that is accompanied by a high fever and swollen lymph nodes should be checked by a medical doctor. Tests may be required to make an accurate diagnosis of the type of infection present.

Which medical professionals can examine and diagnose conditions associated with sore throats?

  • Family physicians or general practitioners (GP)
  • Paediatricians
  • Nurse practitioners
  • Physician assistants
  • ENTs (ear, nose and throat specialists) or otolaryngologists
  • Internists

Diagnosing and treating strep throat

What to do before a doctor’s appointment

If strep throat is suspected, a person can take precautions ahead of their initial doctor’s visit, so as to avoid potentially spreading infection to others. Precautions can include:

  • Practicing good hygiene: Being mindful of covering the nose and mouth if coughing or sneezing, not sharing personal care items (toothbrushes etc) and washing hands frequently.

The following can also be done to help alleviate symptoms and aid in recovery:

  • Gargling with a salt and warm water solution (do not swallow).
  • Taking care to rest, eat soft foodstuffs (where possible) and drink plenty of fluids.

How is a diagnosis made?

Once at the doctor’s office a discussion regarding symptoms, medical history and other relevant information will take place between the health professional and patient. Some questions which a doctor may ask to assess for strep throat include:

  • How long ago did symptoms begin?
  • Have symptoms gotten better or worsened during the time between onset and the appointment?
  • Are symptoms mild in nature or intolerable (severe)?
  • To your knowledge, has anyone you known been diagnosed with strep throat? Have you been in their company recently (last several weeks)?
  • Have you, yourself ever been diagnosed with and treated for strep throat?
  • Do you have any other medical conditions?

From there a doctor will wish to conduct a physical examination and look for signs of inflammation in and around the throat area. He or she will assess the neck for swollen lymph nodes.

Strep throat may be strongly suspected if the following are evident during the consultation:

  • If you are aged between 5 and 15
  • If infection has taken place during the colder months of the year
  • If you have a high fever, swollen and enlarged lymph nodes
  • If you have redness and swelling in the throat
  • If you do have symptoms which are more associated with a bacterial infection rather than a viral one

Young woman at the doctor's office being swabbed for testing.

There is no single diagnostic symptom for strep throat. A test should be done to officially diagnose the condition. In order to make a diagnosis or rule out any other conditions, a doctor may request tests. These may include:

  • Cotton swab stick for strep throat testing.A rapid strep test (rapid antigen detection test): This can be done during the appointment in the doctor’s office. A doctor will gently sweep a long cotton swab across the back of the throat to collect a sample for testing. This will then be packaged and sent to the laboratory for evaluation (i.e. to determine signs of bacteria or antigens). Results can be ready in a matter of minutes (10 to 15 minutes) or up to a few days.
  • A throat culture: Another sterilised cotton swab may be rubbed over the back of the throat to collect a secretion sample. This is then appropriately packaged for analysis in a laboratory where it will be cultured (combined with a substance that promotes bacterial growth). The results may take up to two days (24 to 48 hours) before the presence of bacteria can be determined or identified. The culture will be negative for bacteria if no growth takes place. A throat culture is the more accurate of the two tests and is required for diagnosis of strep throat.

Testing is not normally required in the following instances:

  • A person may have been exposed to strep causing bacteria but displays no symptoms. Testing will only be required when and if symptoms develop (thus making the individual contagious and ill). It is highly unusual to catch strep throat from a carrier (an asymptomatic individual).
  • Following completion of antibiotic treatment, unless symptoms have not cleared. If symptoms recur testing may be required to determine the cause and implement more appropriate treatment.

Colony of bacteria in a culture medium plate or dish.

Treatment for strep throat

1. Oral antibiotics

Once a bacterial infection has been determined, a doctor will prescribe an oral antibiotic to prevent the potential spread of infection and help to reduce the severity and duration of symptoms. This ensures that the risk for complications is considerably reduced as well. Complications include sinus or ear infections, and rheumatic fever.

Although an infection may begin to clear within a day or two, a full course of treatment with antibiotics will need to be taken to ensure that all of the bacteria is killed off. If a full course is not taken, it can cause a recurring bacterial infection, which can often become more difficult to treat or clear with antibiotics (this is known as bacterial resistance).

Antibiotics which are commonly prescribed include penicillin, amoxicillin or cephalexin. Penicillin can be given orally for a period of 10 days or a once-off injection (if oral medications are not tolerated well). An alternative to penicillin is Cephalosporins, a class of antibiotic which is also effective for the treatment of strep throat. For those who may have an allergy to penicillin, macrolides (antibiotics) may be prescribed instead.

Taking antibiotics may not make a person necessarily feel well again, even though the medication is targeting the bacteria in the body causing infection. It is common to experience some side-effects with antibiotic treatment.

Most side-effects are fairly mild. These include:

  • Nausea
  • Vomiting
  • Stomach upsets or tummy aches
  • Loss of appetite
  • Diarrhoea (this can be prevented by taking a course of probiotics simultaneously)

If side-effects become severe, it is best to consult the doctor as soon as possible. In some cases, signs of antibiotic allergy can occur, such as a rash, rapid heartbeat, breathing difficulties and wheezing or dizziness. All of these side-effects require emergency care.

Normally, a person can return to school or the workplace after 24 to 48 hours (as they will no longer be contagious) once antibiotic treatment has started. Antibiotic treatment can help to reduce the duration of the illness by at least a day. If after two days of treatment, there is no symptom improvement, it is best to consult the doctor for a check-up to ensure that there are no further complications.

Example box of antibiotic pills.

2. Over-the-counter pain relievers

For relief of accompanying symptoms such as headache and fever, over-the-counter pain relievers may be recommended. A doctor may also recommend an anaesthetic throat spray to alleviate discomfort, tenderness or pain in the throat.

3. Home care

A doctor will likely request an infected person some time at home to rest, especially while still contagious.

Home care recommendations will include:

  • Plenty of bed rest to aid the body in fighting infection (this promotes recovery).
  • Plenty of warm and soothing liquids such as tea (herbal or liquorice flavour) or lemon water.
  • Consuming soothing foods such as soups, broths, cereals, mashed potatoes, yoghurts, soft-cooked eggs, soft fruits, frozen yoghurt and applesauce, which can be easier to swallow.
  • Avoiding spicy or acidic foods and beverages, and caffeine drinks.
  • Getting plenty of cold liquids, especially water (this can numb the throat a little and provide some relief, aid easier swallowing, as well as prevent dehydration).
  • Using an antibacterial gargle or making a salt water gargling mixture to use at home (not to be swallowed).
  • Sucking on throat lozenges (antibacterial). *not normally recommended for young children
  • Using a cool-mist humidifier.
  • Avoiding irritants such as cigarette smoke, fumes and cleaning products.

Young woman resting in bed.

During the initial 24-hour period of antibiotic treatment a person can take precautions to avoid spreading infection in the following ways:

  • Frequent hand washing with warm water and soap
  • Covering the nose and mouth when coughing or sneezing, especially when around others
  • Using a new toothbrush during initial treatment and replacing it with another once well and the infection has completely cleared (bacteria can collect in toothbrush bristles and potentially re-infect a person)
  • Use tissues that can be thrown away (not reusable cloths and handkerchiefs)

4. Surgery

A surgical procedure may be considered if strep infections continually recur (multiple times in a year), and a person has not had their tonsils removed (tonsillectomy) or is not responding well to antibiotic treatment. Surgery risks versus benefits will be assessed by the attending doctor. If complications of strep throat are of particular concern and infections continuously recur, surgery may be considered the best means of treatment.

Is a follow-up doctor’s visit necessary?

If symptoms do not improve when expected or new symptoms develop, a consultation with a doctor (either in their consulting rooms or an emergency room at a hospital where necessary) is needed.

Severe reactions to antibiotics such as those of an allergy, must be promptly attended to and the medication discontinued immediately.

Antibiotic resistance occurs in a small number of cases. In this instance, another antibiotic may be prescribed for treatment of an infection.

What are some of the most common complications?

Who is most at risk?

  • Children between the ages of 5 and 15.
  • Those in close contact environments where bacterial infections can be easily spread

Common complications

Untreated, strep throat can resolve itself, but antibiotics can help to reduce the likelihood of further infection, resulting in the following possible complications:

  • Sinusitis (sinus infection)
  • Ear infection
  • Scarlet fever
  • Peritonsillar abscess (pus-filled infection of the tonsils)
  • Rheumatic fever (infection of the joints, skin and heart muscle and heart valves)
  • Post-streptococcal glomerulonephritis (kidney inflammation)
  • Guttate psoriasis (a skin condition that results in small, salmon-pink drops on the skin)
  • Mastoiditis (infection of the skull’s mastoid bone)
  • Streptococcal toxic shock syndrome (a potentially life-threatening infection which may cause multi-organ failure)

If bacteria spread, areas of the body which may become infected include the tonsils, sinuses, blood, skin or middle ear.

How to prevent strep throat

Prevention for avoiding an infection is fairly similar to measures taken to reduce the possibility of spreading bacteria. Measures involve practicing good hygiene in frequented areas (the home, office or school environment), regular hand washing, covering the mouth and nose, as well as not sharing personal care items (toothbrushes, towels, razors etc), eating utensils, foodstuffs and drinking containers.

Ensuring that the body is well maintained through a healthy diet and regular exercise can also make it more resistant to frequent infections. Plenty of sleep and managing stress well can also give the immune system a much-needed boost, which can help to better fight off infections when they occur.

There is currently no vaccine available for preventing strep throat infections.

Outlook for strep throat infections

Recurrence of strep infections is not all that common. Most infections are quickly resolved with minimal side-effect with good home-care, over-the-counter medications and where necessary, antibiotics.

What happens if you get strep throat during pregnancy?

Young pregnant woman feeling unwell, sitting on a sofa.It can happen. Pregnancy does not make a woman immune to bacterial, viral or fungal infections. The risk for an expectant mother is much the same as for anyone else with this bacterial infection. The primary need for treatment is to prevent potential complications which can have an adverse effect on both mother and unborn baby.

A pregnant woman will be prescribed antibiotics to treat infection, but will also be carefully monitored. Antibiotics do come with guideline classifications to be taken into consideration when prescribing them to a pregnant patient. Category A medications are usually those which provide the best treatment outcome and little to no risk of harming an expectant mother or her baby. Category B medications indicate that medical professionals must prescribe these with caution. In this instance, the medication has been tested with animals with a set of findings, but no controlled research has been conducted on pregnant women.

The most common antibiotics used to treat strep throat are all classified as category B medications. Animal studies on these medications have shown that use may impact a woman’s fertility or harm a developing baby, to some degree. Antibiotics can access a developing baby via placenta.

A doctor will typically weigh up potential risk against benefits of treatment. Risk of complications may be higher than those associated with a short course of antibiotics. Cephalexin may only be considered during pregnancy when no other options are available. Amoxicillin or penicillin have not shown findings in animal studies that appear to have adverse effects on a developing baby, and may be more commonly prescribed (provided a woman does not have an allergy). Penicillin is not known to pass in breast milk either.

In all cases, a pregnant woman will be carefully monitored during the treatment period. Home care treatment will also be recommended by a doctor to help alleviate symptoms and restore the body to optimum health as quickly as possible.

A pregnant woman should always take preventative measures by trying to avoid those who are sick as much as possible and ensure to stay sufficiently hydrated at all times. An early diagnosis of strep throat is preferable, for anyone, not just an expectant mother. The sooner treatment begins, the quicker development of complications can be avoided.

 

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