Case Studies

Case 1

One morning in mid-December, SC comes to the pharmacy counter carrying IC, her 5-year-old daughter, and asks for advice about a children’s sore throat spray. SC tells the pharmacist her daughter has been complaining of a sore throat for the past 2 days. Upon questioning by the pharmacist, IC denies having a runny nose, cough, mouth sores, and/or hoarseness. The pharmacist recommends a 0.5% phenol oral anesthetic/analgesic spray. Prior to leaving, SC asks the pharmacist whether she should bring IC to the pediatrician to have a strep test performed.

Should IC be tested for strep throat?

Case 2

SC (from the previous case) brings her daughter to a pediatrician, who performs a rapid antigen detection test for GAS pharyngitis. The test comes back positive and the pediatrician decides to write IC a prescription for antibiotics. IC has a known penicillin allergy that previously resulted in hives.

What would be the best antibiotic treatment course for IC?

ANSWERS

Case 1: Group A streptococcal (GAS) pharyngitis (or strep throat) is the most common bacterial cause of acute pharyngitis and is responsible for 20%—30% of all sore throat visits to pediatricians. GAS pharyngitis is most commonly diagnosed in children 5–15 years of age during the winter and early spring (ie, November–May).

Testing for GAS pharyngitis using a rapid antigen detection test or culture allows clinicians to distinguish between GAS and viral pharyngitis, and consequently, determine which patients receive antibiotics (since antimicrobial therapy has not been shown to be beneficial in the treatment of acute pharyngitis due to organisms other than GAS). Testing for GAS is generally indicated in children complaining of a sore throat, except when clinical features strongly suggest a viral etiology (eg, cough, rhinorrhea, hoarseness and/or oral ulcers).

Based upon the time of year and IC’s age and reported symptoms, it would seem reasonable for the pharmacist to recommend IC be tested for strep throat

Case 2: According to Infectious Disease Society of America (IDSA) treatment guidelines, either penicillin or amoxicillin (for 10-days) are the antibiotics of choice for treating children diagnosed with acute GAS pharyngitis. These agents are preferred because of their narrow spectrum of activity, infrequency of adverse reactions and lower cost. However, because IC has previously experienced an allergic reaction when taking penicillin, an alternative agent should be considered. Guidelines suggest penicillin-allergic patients receive oral clindamycin (7 mg/kg/ dose 3 times daily, max=300 mg/dose) or clarithromycin (7.5 mg/kg/dose twice daily, max=250 mg/dose) for 10 days, or oral azithromycin (12 mg/kg once daily, max=500 mg) for 5 days. In addition, SC could consider giving her daughter acetaminophen or an NSAID (not aspirin) if moderate-to-severe symptoms persist or to control a high fever if it occurs.

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Dr. Coleman is associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy