Review Question - QID 105616

This patient's clinical presentation is concerning for a group A streptococcal (GAS) bacterial pharyngitis. The most appropriate next step in management is to perform a rapid antigen detection test (RADT).

In patients with a clinical presentation consistent with bacterial pharyngitis (e.g., tonsilar exuduates, palatal petechiae, painful cervical adenopathy) and absence of symptoms suggestive of a viral source (e.g., cough, coryza, hoarseness, and conjunctivitis), microbiologic testing is needed to determine the presence of a GAS infection. Confirming GAS as the cause of pharyngitis is essential as antibiotic treatment is necessary to prevent the development of suppurative (e.g. otitis media, peritonsillar abscess) and non-suppurative (e.g. acute rheumatic fever) complications. The most appropriate initial test is a RADT. If RADT is negative in children or adolescents in whom GAS pharyngitis is suspected, then a throat culture is necessary to definitively rule out GAS pharyngitis.

Ashurst et. al review the clinical presentation, diagnosis and management of streptococcal pharyngitis. They discuss clinical features that distinguish bacterial pharyngitis from viral pharyngitis. They also discuss the use of RADT in the diagnosis of likely GAS pharyngitis.

Figure A demonstrates an exudative pharyngitis with tonsillar enlargement.

Incorrect Answers:
Answer 1: Amoxicillin would not be an ideal medication option in a patient with a penicillin allergy. Also, it's important to determine the presence of the bacterial infection with microbiologic testing first.

Answer 2: Clindamycin would be a treatment option for patients with a penicillin allergy; however, it must be determined if the patient has a bacterial cause of her symptoms.

Answer 3: Ibuprofen, an antipyretic, can help with improving her fever; however, it does not address the underlying cause of her symptoms.

Answer 5: Throat culture is typically performed in children or adolescents who initially have a negative RADT. It is the most accurate test.

Bullet Summary:
The most appropriate first step in management for a child or adolescent with symptoms consistent with bacterial pharyngitis is a rapid antigen detection test.