ENT  |  Sore Throat Pathway - Assess severity of symptoms and risk of spreading GAS




ENT

Sore Throat Pathway - Assess severity of symptoms and risk of spreading GAS

  • Note >70% sore throats will be viral and do not need antibiotic treatment. In a patient at low risk of ARF the primary consideration should be the avoidance of antimicrobials or throat swabbing.

  • Consider swab and antibiotic treatment if patient unwell and considered to have the potential to develop suppurative complications.

  • Consider swab and/or antibiotic treatment if patient is at increased risk of spreading GAS i.e. Healthcare workers, food handlers (i.e. any person who comes into direct contact with food or the equipment or utensils used to prepare food e.g. cooks, waiting staff etc), school and early childhood teachers and students. They should be isolated for 24 hours post starting a course of antibiotics OR until their throat swab result returns a negative result (if the choice is taken not to empirically treat).

  • For children with severe recurrent tonsillitis, tonsillectomy does offer benefit, by reducing the number of sore throats in the short term (12 months). As a guide, 7 episodes in the preceding 12 months, or 5 in each year for 24 months, or 3 per year for 3 years may warrant consideration, taking account of the clinical severity of episodes (see page 44 of Guidelines).

  • There is insufficient data to make a definitive recommendation on the use of tonsillectomy in treating recurrent GAS pharyngitis (see page 45 of Guidelines). 

The information below taken directly from the 2014 Guidelines provides a little more clarity with regard to the advice.


Reference: New Zealand Guidelines for Rheumatic Fever; 2014 Update; pg 26

Management of Pharyngitis in Patients at Low Risk of Rheumatic Fever:

Patients who are at low risk for rheumatic fever include:

  • Non-Māori and non-Pacific people.

  • Children under 3 years old and adults older than 35 years old.

  • Not living in crowded circumstances or lower socioeconomic areas of North Island If there is a personal, family or household history of acute rheumatic fever the person is automatically at high risk.

Most sore throats, in both children and adults, are viral in origin. In the population at low risk of ARF, minimising throat swabbing, unnecessary antibiotic treatment and healthcare expenditure should be the aim. In these populations, it may be appropriate to consider associated symptoms such as rhinorrhoea and cough in order to avoid potentially unnecessary antibiotic prescribing, as the consequences of missing a true GAS pharyngitis are low. Significantly unwell patients however, require active diagnosis and management, particularly where symptoms are unilateral and the development of local suppurative complications such as peritonsillar abscess needs to be considered.

The utility of throat swabbing for wider community benefit should be taken into account. Adults presenting with symptomatic pharyngitis who have otherwise been assessed as being low risk for ARF, should be assessed (based on their employment) for their risk for spreading GAS in the workplace to those at high risk for ARF.

If they are assessed as being at increased risk of spreading GAS, it is recommended that a throat swab be taken for culture and if GAS positive, they should be treated with appropriate antibiotics.

Reference: New Zealand Guidelines for Rheumatic Fever; 2014 Update; pg 42-43.

Who is at increased risk of spreading GAS?

Group A streptococcus is spread through droplets of saliva or nasal secretions, as well as in water and food preparation. Nasal GAS infection has also been implicated by Hamburger et al(1945) and Jarrett et al (1950).

GAS spread has been demonstrated to occur in a variety of settings, including households, military barracks, classrooms, day care, hospitals and residential care. A GAS outbreak in Christchurch in 2014 in an aged care facility led to five deaths.

Those at increased risk of spreading GAS include:

  • Healthcare and residential care workers (Pichichero & Casey 2007A,4 expert opinion)
  • Food handlers (Darrow 2002,5 NZ Government 2013)
  • Teachers (expert opinion, NZ Government 2013)
  • Childcare workers (expert opinion)


Adults presenting with symptomatic pharyngitis who have otherwise been assessed as being low risk for ARF, should be assessed, based on their employment, for their risk for spreading GAS in the workplace to those at high risk for ARF. If they are assessed as being at increased risk of spreading GAS, it is recommended that a throat swab be taken for culture and if GAS positive, they should be treated with appropriate antibiotics. In addition, the Health (infectious and Notifiable Diseases).

Regulations allow for seven days exclusion from work or school to be enforced for teachers and students with GAS pharyngitis. As stated earlier, this legislation is rarely invoked.



Last updated : Friday, August 21, 2015
Next review date : Saturday, August 20,2016


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