Strep throat or tonsillitis

Strep throat or tonsillitis

Streptococcal infection is one of the most common infections in childhood, and a very common reason for antibiotic therapy.
Despite this infection being known to humankind for many years, there is still confusion when it comes to understanding the cause, diagnosis and management of strep throat. And it’s really a pity.
The references used to write this post are diverse, from different national clinical guidelines to official guidelines from the American association for pediatrics (published in 2012), and an infectious diseases book (Red Book). But mostly, it is based on my own personal experience with this infection.
I’m happy to announce that this is one of the chapters on this website that I am most pleased with. It has lots of information and answers to questions that I get asked by parents quite often.
So, try to remain focused and I am sure you will find the answers to your specific questions here.


How is this illness referred to? Throat infection? Tonsillitis? Pharyngitis?

These two different terms are quite similar.
Throat infection or pharyngitis – redness and pain in the back of the throat.
Tonsillitis – redness, pain and sometimes white exudates on the tonsils.
The tonsils are a lymphatic tissue found in the back of our throats.
There is, however, a slight clinical difference between these two terms. What I mean is that there is a difference between seeing a throat that is slightly red and seeing tonsils full of white pus. Even though, practically speaking, and for the purpose of this chapter, I will be using the term throat infection to describe all these different infections.

What causes throat infection in children (and adults)?

Throat infection is caused mostly by viruses, many different respiratory viruses but also viruses such as Epstein-Barr Virus and Cytomegalovirus that cause an infection called “kissing disease” or infectious mononucleosis. Learn more about infectious mononucleosis in the link here.
A small percentage of throat infections are caused by bacteria, mainly Group A Streptococcus.

What are the clinical manifestations of throat infections in general, and in those caused by Streptococcus in particular?

Strep throat tends to develop quickly (acutely) and includes symptoms such as fever, headache, pain on swallowing and abdominal pain. The child may have a characteristic voice referred to as “hot potato voice”.
A characteristic rash can develop indicating the onset of scarlet fever, see more about this below or in the link here.
When examining the throat, you can usually see redness behind the palate, swelling and redness of the tonsils as well as the presence of white exudates covering the tonsils. It is also common to find swollen and tender lymph nodes in the neck region.
Absence of fever and presence of symptoms such as cough, runny nose, eye infection or hoarseness indicate a viral infection, rather than a bacterial infection.

What age group does strep throat typically affect?

Strep throat is common in children 5 through 15 years old, but it can of course also affect people who are older or younger. Many times, parents catch strep from their kids and here and there I’ve seen grandmas catch it from their grandchildren…
The infection is not common in children under the age of 3 years. Even if you tell me that your 1-year-old tested positive for strep I can assure you that he/she are simply carriers and not actually ill. Keep reading to find out more.
There could be real cases of strep throat in children aged 2 years. These are, however, rare and will usually occur in children who have older siblings or who attend daycares with older children (over the age of 3). But this is still much less common.
So, if your physician tested your child, who is under 2 years, for strep throat (or worse, if they actually prescribed an antibiotic without testing first), try to ask them why they did so, because this will usually be a mistake. Even if the test comes back positive, as you will see below.

Can the physician (or mother) diagnose the cause of the throat infection just by looking at the throat?

Absolutely not! That type of attempt is just bound to fail. An experienced mother or physician will look into a child’s mouth and think to themselves (or out loud), “oh this looks like strep”, but even the best of doctors and best of mothers will not be able to identify the causing pathogen just by looking at the throat.
For example, throat infection due to infectious mononucleosis (find out more about it here) can look exactly like strep throat, at least in terms of the appearance of the throat.
There have been attempts in the past to try and create a scoring system that will help predict the likelihood of strep throat in children complaining of sore throat. Nonetheless, the ability of these scores to make an accurate prediction are low.
And therefore, because of this, every time there is a concern for strep throat you must make a proper microbiological diagnosis, which usually means taking a swab to test for strep.

What are the different types of throat swabs out there?

Rapid strep test – the main advantage to this test is that you get your result on the spot. A positive result confirms the presence of Group A Strep in a child’s throat. This swab is about 70-90% accurate, so if you get a negative result you have to obtain a regular throat culture. How to (successfully) take a throat culture from a child or an adult? Read here.
By the way, this is the only section in this post where management in adults will be different than in children. According to the official guidelines for adults, there is no need to obtain a regular throat culture if the rapid test is negative.
Throat culture – this is considered the most accurate test for strep throat. The only issue is that it takes time for the results to come out (approximately 2 days).

Is the swab always positive at the beginning of the illness?

This is a question I get asked almost every day. A classic scenario is a child that comes into a doctor’s office with a concern for strep throat. The doctor swabs the child and the mother questions whether a throat swab taken so early in the disease is reliable.
The answer is yes. If the child has strep throat, a test taken in the first few hours after the onset of symptoms will indicate strep throat (and I’ll tell you a secret, a test taken before those few hours will be positive, as well!). And if the result is negative and the swabbing technique was adequate, then the bacteria will not just pop up tomorrow.

How is a throat swab taken?

To reduce the probability of getting a false negative result, it is best to have a skilled professional perform the test.
I know that many parents do the throat swab either at home or at the pharmacy. When the swab is positive, streptococcus has been isolated in the throat. When the swab is negative and there is a reasonable concern for strep, see a professional and repeat the test.
My tips for taking a proper swab are to make sure the swab touches both tonsils and the back of the pharynx.
Often, a tongue depressor is required to push the child’s tongue down while swabbing. And why is that? This is because it is difficult to reach the back of the pharynx without depressing the tongue. Contact with the tongue is often the reason for false negative results.
You can read more about proper swabbing techniques in the link here.
And another word for parents who swab their kids at home, read the next paragraph before proceeding to do this. The fact that your child has streptococcus in their throat does not necessarily mean he/she has the infection.
Please avoid the unnecessary usage of antibiotics.

If the swab confirmed the presence of streptococcus bacteria, does this mean my child certainly has strep throat infection?

The answer to this is complex.
There is a large percentage of carriers in the general population (about 10-15%). There could be a scenario where a child comes to the office with a runny nose and a red throat – signs of a viral infection. If the physician decides to test him/her for streptococcus, the chance of isolating streptococcus is the same as the carrier rate in that same population. And then, getting a positive result will lead to unnecessary antibiotic treatment.
So, how can we distinguish between carrier state to the presence of bacteria because of a real infection? A throat swab should be taken only in children presenting with an acute illness that is likely due to streptococcus. In other words – a child in the common age group presenting with the characteristic clinical signs and symptoms of strep throat.
When a physician takes a throat swab, they are committing to the possibility of a real streptococcal infection that requires antibiotic treatment if positive.
Throat swabs should not be taken just for fun, in children who are not showing real signs of strep throat. They should never be taken just because the parents requested it.
I’ve been hearing about many children who get tested at the pharmacy lately. I think these tests should only be done after thorough history taking and clinical assessment.
Have a skilled healthcare professional take a look at your throat and determine whether there is a need for a throat swab. Don’t just go and get tested by someone that does the test without a full assessment.

So, are rapid strep tests useful?

When taken by skilled hands, rapid strep tests are a true asset when it comes to diagnosis and shortening of disease in children.
If your family physician does not have these tests in their office, I suggest you buy one and go to your family physicians with it.
If your physician suspects strep throat, you can ask them to perform the test using the rapid test that you purchased and by doing so to fasten the process and confirm the need for treatment.
Again, I encourage you not to make decisions on your own. See your family physician and allow them to make an educated decision based on their physical examination.

What is the treatment of choice for strep throat?

The treatment of choice for those who do not have any known allergies to penicillin are penicillin derivatives – amoxicillin or penicillin V.
Since streptococcus is a drug that has not developed resistance to penicillin, if a person is not allergic to penicillin there is no need to treat strep with any other antibiotic.
Let me write this down clearly:
There are no advantages to treatment with amoxicillin-clavulanic acid over penicillin, when it comes to strep throat. On the contrary, there are disadvantages.
There are no advantages to treatment with azithromycin over penicillin (unless a person is allergic to penicillin). Only disadvantages.
There are no advantages to cephalexin over penicillin, only disadvantages.
I know that there are people who can swear that their throat infections only ever get better with amoxicillin-clavulanic acid. I apologize, but this is simply nonsense. Find out more about what happens to people who take wide-spectrum antibiotics when they are unnecessary here.
I will touch on what happens when there are recurrent strep throat infections later on, but I will just take this opportunity to emphasize that there are no advantages to prescribing other antibiotics when it comes to recurrent infections either – the management just has to be different.

Why is it important to treat strep throat?

There are several reasons, these include:
 Shortening the illness – a child on antibiotics will recover quicker than a child who isn’t being treated.
 Prevention of local pustular complications – for example, a tonsillar abscess
 Prevention of transmission of infection – a child who is being treated stops being infectious quite quickly, see below.
 Prevention of immunological complications – especially rheumatic fever (cardiac and joint involvement following a strep throat that was not treated adequately). Despite this being a rare complication, it is very unpleasant. A child who received full treatment will not develop rheumatic fever.

When should treatment be started when strep throat is suspected?

If there is clinical suspicion for strep throat and the rapid strep test was positive, treatment should be started immediately.
If a throat culture was obtained and the results will only be available in a couple days, you have several options:
Either start treatment immediately, and then if the result is positive – continue, otherwise if the result is negative – stop the treatment.
Or wait for the official results and start treatment only if the result is positive.
I think that when the concern for strep throat is reasonable, or when the child has fever and is suffering, it is a good idea to start treatment as soon as the culture is obtained.
When the clinical signs and symptoms are not clear cut, waiting for the results is the better option.
To prevent late complications as mentioned above, it is important to start treatment within the first 9 days after onset of symptoms.

What is the correct dosage for treatment and what is the correct duration of treatment?

The dosage is relatively low, since the absorption of penicillin is excellent and the pathogen is very sensitive to it.
For amoxicillin, the dose is 50mg/kg/day divided into 2 doses for children. The maximum dosage that can be given is 500mg twice a day (for adults too). This is a relatively low dose when compared to the dose needed for other infections/pathogens that are treated with amoxicillin.
Practically speaking, for every child/adult that weighs over 20kg, the dose is 500mg twice daily.
For those of you who like to take this medication three times a day, or prefer taking two pills together when they first start treatment… and all this other made up conceptions – they really do not make any difference to the course of the illness.
It is also possible to take the entire dose in one go. That means taking the full daily dose, once a day.
The duration of treatment is 10 days. Take note, often times the child will start feeling better one day after starting treatment and the parents quickly forget why they even started the antibiotic to begin with. But it is really important to complete the 10 days of treatment to ensure the eradication of the bacteria from the throat and to prevent recurrent episodes, as you will see below.
The treatment of scarlet fever (see the link here) is similar to the treatment of strep throat.

How quickly should I expect recovery or resolution of symptoms once treatment has begun?

In children recovery is very fast. Symptoms resolve within 24-48 hours after treatment has been started.

In adults, things can take a little longer…

But while you wait for the antibiotics to start working, don’t forget to treat your child with analgesics (painkillers) and anti-pyretics to reduce fever.

When is a child no longer contagious and when can they return to normal activities?

When it comes to daycare or school, you must make sure it has been at least 12 hours since the start of treatment and that your child has been fever-free for 24 hours.

When it comes to normal activities – your child will be able to resume activities as soon as their fever resolves, and they feel better. You do not need to wait until they have completed their full course of antibiotics. And also, antibiotic treatment does not weaken your child!

Is it necessary to repeat the throat swab at the end of the course of treatment?

Generally, no.

Taking another swab at the end of treatment just to confirm eradication of the pathogen is not usually required and most of the time, when requested by the physician, it represents an error in judgement and management of the case.

What happens if the infection recurs?

Unfortunately, infections can recur. It can either be because of re-infection from a family member or friend that is a carrier or is ill or because sometimes the pathogen is not fully destroyed, even when we complete 10 days of treatment.
When a recurrent infection is suspected, the same principles that guided us in the initial diagnosis must be repeated:
Make sure to take the correct dose of antibiotics for the full 10 days and do not stop the treatment one day after the child starts feeling better.
Take a throat swab only when there is a solid clinical concern. Do not obtain a throat swab in children/adults with a runny nose and a mild throat irritation.
Remember to always test for strep prior to starting antibiotics.
The best antibiotic for strep, even in recurrent infections, is simple penicillin. In my opinion, and despite there being other opinions out there, I do not think there are any advantages to other antibiotics over penicillin when it comes to strep throat.

Some children and families have a lot of recurrent strep infections. What should be done?

First of all, proper diagnoses is crucial – both clinical and microbiological.
Keep in mind that in populations where the carrier rate is about 15%, if you test a class of 40 healthy children, you will isolate strep in about 6 children.
Therefore, it is important to make sure that the clinical signs and symptoms fit strep throat infection (there is usually high fever and typical findings in the throat) and microbiological proof is obtained.
Also, it is important to consider other possible diagnoses that can be mistaken as strep throat. Viruses are also capable of recurrent throat infections, and we have to make sure that the diagnosis of strep throat was correct.
In addition, when it comes to throat infection that recur in a cyclic manner, every 3-6 weeks, we have to consider the possibility of PFAPA, a non-infectious, inflammatory disease. I have seen many children who had what appeared to look like “recurrent throat infections” and ended up actually having PFAPA. An episode of PFAPA is treated with a single dose of steroids.
In fact, there are a lot of parents among us that complain of having had recurrent strep throat infections. Many of them probably had PFAPA, but PFAPA was not a known disease at the time. Read more about PFAPA in the link here.
Very rarely, and in exceptional cases that happen once or twice a year, do I suspect a case of multiple infections within a family, where family members infect and reinfect each other over a period of time. In such cases I test the entire family to see whether or not some of them are carriers and then I consider treating the carriers.
Treatment of carriers consists of 10 days of penicillin. On the last 4 days of treatment, I prescribe an additional antibiotic – penicillin V. Tonsillectomies are no longer a common way to manage recurrent strep infections these days.


Here are the 10 most important rules for diagnosis and management of strep throat:

  • Most throat infections in children are caused by viral pathogens
  • Strep throat is not common (at all) in children under the age of 3 years
  • Carrier rates in the general population are up to 15%, and therefore, except for very few situations, a healthy child or a child presenting with viral symptoms (absence of fever, presence of runny nose and cough) should not be tested for strep.
  • Since making a clinical diagnosis is difficult, whenever strep throat is suspected the suspicion must be confirmed with the help of a throat swab (rapid swab or bacterial culture).
  • The swabbing technique must be done properly. When there is a real concern for strep and the rapid swab test is negative, a culture must be obtained.
  • The treatment of choice in both children and adults who are not allergic to penicillin is simple penicillin for a duration of 10 days.
  • There is no need to repeat the swab following completion of treatment.
  • As a general rule, identification and treatment of carriers should be avoided.
  • If the infection recurs, a swab test and treatment should be repeated as done in the initial diagnosis. It is important to make sure to complete a full, 10-day course of treatment.
  • When a child seems to be suffering from recurrent throat infections, they should be referred to a specialist to determine whether it is recurrent strep throat or a different medical condition (such as PFAPA).

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