Group A beta-hemolytic streptococci (GABHS) are bacteria that cause a variety of infections in children, most commonly tonsillopharyngitis (strep throat). GABHS infection cannot be diagnosed based on symptoms alone and requires a rapid strep test or culture. While penicillin remains the gold standard treatment, other antibiotics like cephalosporins and azithromycin are also effective, especially since they have better compliance rates with shorter 5-day treatment durations. GABHS spreads through close contact with infected individuals and can cause complications like rheumatic fever if left untreated.
Mumps is an acute viral infection caused by the mumps virus, which typically involves swelling of the parotid glands. It is spread through direct contact, airborne droplets, or fomites contaminated by saliva. While complications are rare, they can include meningoencephalitis, orchitis, oophoritis, pancreatitis, and myocarditis. Diagnosis is usually based on clinical symptoms and confirmed through serologic testing or virus isolation. Treatment is supportive, and vaccination provides effective prevention against mumps infection and its complications.
This document describes a diagnostic algorithm developed by the CDC to evaluate patients presenting with acute febrile vesicular or pustular rash illnesses and assess their risk of being infected with smallpox. The algorithm aims to classify cases into high, moderate, or low risk categories based on clinical criteria to guide patient management and determine if smallpox testing is required. It was created due to renewed concerns about smallpox as a bioterrorism agent and to avoid unnecessary testing. The CDC's use of the algorithm since 2002 has effectively ruled in varicella and ruled out the need for smallpox testing in evaluated cases.
This document discusses several viruses that can infect the oral cavity, including human papillomavirus (HPV), herpesviruses, mumps virus, and coxsackieviruses. It provides details on the structure, transmission, clinical manifestations, diagnosis and treatment of infections caused by HPV, herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6 in the oral cavity. Common oral infections discussed include oral warts, oral hairy leukoplakia, and infectious mononucleosis.
1. Epstein Barr Virus (EBV) is a common human herpesvirus that causes infectious mononucleosis and is associated with several cancers.
2. EBV typically infects individuals during childhood when it usually does not cause symptoms, but in teenagers and adults it can cause infectious mononucleosis with symptoms like fatigue, fever, sore throat, and swollen lymph nodes.
3. While symptoms usually resolve within a few weeks, some people may feel fatigued for several months. EBV is lifelong infection that can reactivate and cause oral hairy leukoplakia in immunocompromised individuals.
it is an acute highly contagious /infectious diseases caused by a varicella zoster virus. chicken pox is usually a mild self limiting illness and most healthy children recover with no complication.
Anyone who has had chickenpox in the past may develop shingles, you can only get shingles if you have previously had chicken pox as it is a recurrence or reactivation of the varicella zoster virus.it is not possible to develop shingles from exposure to a person with chickenpox it is possible however to develop chickenpox as a result of exposure to a person with shingles second attacks of chickenpox are rare but do occur.
Bacterial infections can cause diseases that manifest in the oral cavity. Some diseases like scarlet fever are caused by specific bacteria, while others can be caused by a broad group of microorganisms. Common bacterial infections discussed in the document include scarlet fever caused by Streptococcus pyogenes, diphtheria caused by Corynebacterium diphtheriae, and tuberculosis caused by Mycobacterium tuberculosis. These bacteria can cause lesions, ulcers, and pseudomembranes in the oral cavity. Diagnosis involves identifying the bacteria through cultures or identifying their characteristics through microscopic examination after staining.
the most common viral infections that affects the maxillofacial area
sources( burket's oral medicine 11th ed,oral and maxillofacial pathology neville 2e )
This document summarizes various viral infections that can affect the oral cavity, including herpes simplex virus, which causes recurrent lesions. It also discusses measles, rubella, molluscum contagiosum, varicella, herpes zoster, and mumps. The document provides details on HIV/AIDS transmission and stages of infection. Finally, it outlines several oral manifestations that can occur in HIV/AIDS patients, such as candidiasis, histoplasmosis, linear gingival erythema, and Kaposi's sarcoma. Treatment involves highly active antiretroviral therapy and managing symptoms.
Mumps is an acute viral infection caused by the mumps virus, which typically involves swelling of the parotid glands. It is spread through direct contact, airborne droplets, or fomites contaminated by saliva. While complications are rare, they can include meningoencephalitis, orchitis, oophoritis, pancreatitis, and myocarditis. Diagnosis is usually based on clinical symptoms and confirmed through serologic testing or virus isolation. Treatment is supportive, and vaccination provides effective prevention against mumps infection and its complications.
This document describes a diagnostic algorithm developed by the CDC to evaluate patients presenting with acute febrile vesicular or pustular rash illnesses and assess their risk of being infected with smallpox. The algorithm aims to classify cases into high, moderate, or low risk categories based on clinical criteria to guide patient management and determine if smallpox testing is required. It was created due to renewed concerns about smallpox as a bioterrorism agent and to avoid unnecessary testing. The CDC's use of the algorithm since 2002 has effectively ruled in varicella and ruled out the need for smallpox testing in evaluated cases.
This document discusses several viruses that can infect the oral cavity, including human papillomavirus (HPV), herpesviruses, mumps virus, and coxsackieviruses. It provides details on the structure, transmission, clinical manifestations, diagnosis and treatment of infections caused by HPV, herpes simplex virus, varicella zoster virus, Epstein-Barr virus, cytomegalovirus, and human herpesvirus 6 in the oral cavity. Common oral infections discussed include oral warts, oral hairy leukoplakia, and infectious mononucleosis.
1. Epstein Barr Virus (EBV) is a common human herpesvirus that causes infectious mononucleosis and is associated with several cancers.
2. EBV typically infects individuals during childhood when it usually does not cause symptoms, but in teenagers and adults it can cause infectious mononucleosis with symptoms like fatigue, fever, sore throat, and swollen lymph nodes.
3. While symptoms usually resolve within a few weeks, some people may feel fatigued for several months. EBV is lifelong infection that can reactivate and cause oral hairy leukoplakia in immunocompromised individuals.
it is an acute highly contagious /infectious diseases caused by a varicella zoster virus. chicken pox is usually a mild self limiting illness and most healthy children recover with no complication.
Anyone who has had chickenpox in the past may develop shingles, you can only get shingles if you have previously had chicken pox as it is a recurrence or reactivation of the varicella zoster virus.it is not possible to develop shingles from exposure to a person with chickenpox it is possible however to develop chickenpox as a result of exposure to a person with shingles second attacks of chickenpox are rare but do occur.
Bacterial infections can cause diseases that manifest in the oral cavity. Some diseases like scarlet fever are caused by specific bacteria, while others can be caused by a broad group of microorganisms. Common bacterial infections discussed in the document include scarlet fever caused by Streptococcus pyogenes, diphtheria caused by Corynebacterium diphtheriae, and tuberculosis caused by Mycobacterium tuberculosis. These bacteria can cause lesions, ulcers, and pseudomembranes in the oral cavity. Diagnosis involves identifying the bacteria through cultures or identifying their characteristics through microscopic examination after staining.
the most common viral infections that affects the maxillofacial area
sources( burket's oral medicine 11th ed,oral and maxillofacial pathology neville 2e )
This document summarizes various viral infections that can affect the oral cavity, including herpes simplex virus, which causes recurrent lesions. It also discusses measles, rubella, molluscum contagiosum, varicella, herpes zoster, and mumps. The document provides details on HIV/AIDS transmission and stages of infection. Finally, it outlines several oral manifestations that can occur in HIV/AIDS patients, such as candidiasis, histoplasmosis, linear gingival erythema, and Kaposi's sarcoma. Treatment involves highly active antiretroviral therapy and managing symptoms.
An outbreak of measles occurred in 2018, with 292 cases reported across 26 states. Measles is highly contagious and spreads through the air via respiratory droplets. Those at highest risk are unvaccinated children and individuals. An investigation into the outbreak followed 13 steps: establishing the diagnosis, constructing a case definition, finding cases, descriptive analysis to generate hypotheses, evaluating hypotheses, refining hypotheses based on additional studies, implementing control measures like isolation and immunization, maintaining surveillance, and communicating findings. The outbreak was likely due to increased travel and declining vaccination rates in some communities.
This document provides information about chickenpox and shingles. It discusses the origin of the term "chickenpox", the virus properties, epidemiology and pathogenesis of varicella zoster virus. It describes the clinical features and treatment of chickenpox and shingles. Complications like secondary bacterial infections and post-herpetic neuralgia are also summarized. The diagnosis and management of both chickenpox and shingles infections are outlined in less than 3 sentences.
describes the etiopathogenesis , clinical features, investigations, differential diagnosis and management and prophylaxis of all important viral lesions affecting the oral cavity
Chickenpox is caused by the varicella zoster virus and causes an itchy rash and blisters all over the body. It is highly contagious and spreads through direct contact or respiratory droplets. While usually mild in children, it can cause more serious complications in adults like pneumonia or encephalitis. Treatment focuses on relieving itching and fever and prevention includes vaccination.
AIDS is a fatal illness caused by the HIV virus which weakens the immune system. It is most common in sexually active adults aged 20-49 and can be transmitted through unprotected sex, blood exposure, or from mother to child during pregnancy or breastfeeding. While there is no cure for AIDS, prevention methods like condom use and sterile needle practices can reduce transmission rates. People infected with HIV may not show symptoms for years but can still transmit the virus, so testing and early treatment are important for controlling the spread of the disease.
Viral infections of oral cavity - Dr. Abhishek SolankiAbhishek Solanki
This document discusses various viral infections including herpes simplex virus, varicella, herpes zoster, infectious mononucleosis, cytomegalovirus, enteroviruses, rubeola, rubella, mumps, and human immunodeficiency virus. It provides details on the causative viruses, clinical manifestations, histopathological features, diagnosis and treatment of each infection. Complications are also mentioned for some viruses. Classification systems for HIV infected patients based on CD4 count and clinical categories are summarized.
Chickenpox is caused by the varicella-zoster virus and causes a characteristic itchy vesicular rash. It is highly contagious and spreads through respiratory droplets. The rash progresses rapidly from macules to papules to vesicles and crusts over within 4-7 days. Complications can occur in immunosuppressed individuals and include pneumonia and encephalitis. Vaccination with the live attenuated varicella vaccine provides effective protection.
The document summarizes ENT manifestations of HIV infection. It describes how HIV attacks CD4 cells leading to opportunistic infections and malignancies. Common ENT issues seen include oral thrush, recurrent sinusitis, sensorineural hearing loss, and Kaposi sarcoma of the oral cavity, nose and larynx. Diagnosis involves CD4 counts and virus detection tests. Universal precautions are essential to prevent transmission among health workers.
The document summarizes several common pediatric infections and exanthematous diseases:
1) It discusses rubella (German measles), including its etiology, symptoms of a pink maculopapular rash and lymphadenopathy, and prevention through MMR vaccination.
2) It describes rubeola (measles), caused by a paramyxovirus, with symptoms of a red maculopapular rash following a prodrome of fever and upper respiratory symptoms.
3) It briefly outlines varicella (chickenpox), caused by varicella-zoster virus, presenting with a centripetal vesicular rash that is highly contagious until lesions crust over.
This document discusses various medical conditions that cause rashes or lesions in the mouth (enanthems). It provides 10 cases describing the presentation of oral rashes caused by conditions such as candidiasis, herpangina, hand-foot-and-mouth disease, herpetic gingivostomatitis, eruptive gingivitis, necrotizing gingivostomatitis, aphthous ulcers, Behcet's syndrome, and geographic tongue. It also mentions dental cysts. The document compares the clinical features of these various conditions to determine the most likely diagnosis for each case.
This document discusses cutaneous manifestations of HIV infection that can be caused directly by HIV or opportunistic infections due to immune deficiency. It classifies the manifestations into viral (such as herpes, molluscum contagiosum, EBV), fungal (candidiasis, cryptococcosis), bacterial (mycobacteria, syphilis, Staphylococcus), and parasitic (scabies, leishmaniasis). Recognizing these cutaneous signs is important for diagnosing HIV infection and providing appropriate antiretroviral therapy.
This document discusses ENT manifestations of AIDS. It begins by providing background on HIV, noting that it attacks CD4 cells. When CD4 counts fall below 200, opportunistic infections and malignancies can develop. ENT issues are then reviewed, including candidiasis, Kaposi's sarcoma, herpes zoster, Bell's palsy, sinusitis, oral thrush, hairy leukoplakia, and recurrent tonsillitis. Neck lymphadenopathy can indicate bacterial or mycobacterial infections, P. carinii, toxoplasmosis or fungal infections. Overall, the document outlines the varied ENT presentations associated with HIV/AIDS and emphasizes the need for a high index of suspicion to properly
This document summarizes information about Neisseriaceae and Bacillus species. It describes the main human pathogens in Neisseriaceae as Neisseria gonorrhoeae, which causes gonorrhea, and N. meningitidis, which causes meningitis. N. gonorrhoeae infections are highly prevalent but have low mortality, while N. meningitidis has low prevalence but high mortality. Clinical manifestations, diagnosis, treatment and control measures are discussed for both pathogens. Other genera in Neisseriaceae including Moraxella are also summarized.
The document discusses the assessment of children with recurrent chest infections. It can be a difficult diagnostic challenge to determine if a child has a simple cause like viral infections or asthma, or a more serious underlying issue like cystic fibrosis, immunodeficiency, or congenital abnormalities. A detailed history, physical exam, and selective investigations are needed to distinguish between self-limiting issues and serious progressive lung disease. Recurrent respiratory infections are common in childhood but the aim is to identify those with severe or long-term lung pathology.
Viral infection of the respiratory tract (2)Ravi Teja
The document discusses several viruses that can cause respiratory infections, including adenoviruses, respiratory syncytial virus, and parainfluenza viruses. It provides details on the structure, transmission, clinical manifestations, diagnosis, and treatment of infections caused by these viruses. Adenoviruses can cause pharyngitis, pneumonia, conjunctivitis and other syndromes. RSV is a major cause of bronchiolitis and pneumonia in infants. Parainfluenza viruses commonly cause croup in young children.
Fungal infections can be caused by yeasts, molds, or dimorphic fungi. Common fungal infections include candidiasis, dermatophyte infections, and systemic mycoses. Candida commonly causes oral and vaginal infections. Dermatophytes cause ringworm. Systemic mycoses like histoplasmosis and aspergillosis primarily affect immunocompromised individuals. Diagnosis involves microscopy, culture, antigen testing, or molecular methods. Treatment depends on the infecting fungus and severity of infection, ranging from topical antifungals to intravenous antifungals.
- Herpes simplex virus types 1 and 2 are common oral viral infections, usually transmitted via saliva or direct contact. Both viruses establish latency in ganglia. HSV-1 typically causes oral lesions while HSV-2 typically causes genital lesions.
- Varicella zoster virus causes chickenpox in children and shingles in adults via reactivation. It establishes latency in ganglia.
- Epstein-Barr virus causes infectious mononucleosis, commonly known as "mono" or "kissing disease". It is transmitted through saliva and causes fever, lymphadenopathy and pharyngitis.
Cutaneous manifestations are common in HIV patients, occurring in over 90% of cases. They can represent the first signs of HIV infection and have prognostic significance. Skin conditions in HIV patients often present atypically with lesions in unusual sites, atypical morphology, being more extensive or not responding to conventional treatments. Common manifestations include generalized rashes, oral/genital ulcers, seborrheic dermatitis, psoriasis, papulopruritic eruptions, eosinophilic folliculitis, granuloma annulare, bacterial/viral infections like herpes, fungal infections, and Kaposi sarcoma. It is important to consider HIV when patients present with rare or unusual skin
This document discusses HIV and its effects on the ENT system. It begins by explaining what HIV is and how it attacks the immune system. It then discusses the epidemiology of HIV and current global statistics. Various opportunistic infections that can affect the ENT system are described, including fungal infections of the ear, sinusitis, neoplasms like Kaposi's sarcoma, and lymphomas of the nose and oral cavity. Manifestations in different areas like the ear, nose, oral cavity and airways are summarized. Risk groups, disease progression, and treatment approaches are also briefly covered.
An outbreak of measles occurred in 2018, with 292 cases reported across 26 states. Measles is highly contagious and spreads through the air via respiratory droplets. Those at highest risk are unvaccinated children and individuals. An investigation into the outbreak followed 13 steps: establishing the diagnosis, constructing a case definition, finding cases, descriptive analysis to generate hypotheses, evaluating hypotheses, refining hypotheses based on additional studies, implementing control measures like isolation and immunization, maintaining surveillance, and communicating findings. The outbreak was likely due to increased travel and declining vaccination rates in some communities.
This document provides information about chickenpox and shingles. It discusses the origin of the term "chickenpox", the virus properties, epidemiology and pathogenesis of varicella zoster virus. It describes the clinical features and treatment of chickenpox and shingles. Complications like secondary bacterial infections and post-herpetic neuralgia are also summarized. The diagnosis and management of both chickenpox and shingles infections are outlined in less than 3 sentences.
describes the etiopathogenesis , clinical features, investigations, differential diagnosis and management and prophylaxis of all important viral lesions affecting the oral cavity
Chickenpox is caused by the varicella zoster virus and causes an itchy rash and blisters all over the body. It is highly contagious and spreads through direct contact or respiratory droplets. While usually mild in children, it can cause more serious complications in adults like pneumonia or encephalitis. Treatment focuses on relieving itching and fever and prevention includes vaccination.
AIDS is a fatal illness caused by the HIV virus which weakens the immune system. It is most common in sexually active adults aged 20-49 and can be transmitted through unprotected sex, blood exposure, or from mother to child during pregnancy or breastfeeding. While there is no cure for AIDS, prevention methods like condom use and sterile needle practices can reduce transmission rates. People infected with HIV may not show symptoms for years but can still transmit the virus, so testing and early treatment are important for controlling the spread of the disease.
Viral infections of oral cavity - Dr. Abhishek SolankiAbhishek Solanki
This document discusses various viral infections including herpes simplex virus, varicella, herpes zoster, infectious mononucleosis, cytomegalovirus, enteroviruses, rubeola, rubella, mumps, and human immunodeficiency virus. It provides details on the causative viruses, clinical manifestations, histopathological features, diagnosis and treatment of each infection. Complications are also mentioned for some viruses. Classification systems for HIV infected patients based on CD4 count and clinical categories are summarized.
Chickenpox is caused by the varicella-zoster virus and causes a characteristic itchy vesicular rash. It is highly contagious and spreads through respiratory droplets. The rash progresses rapidly from macules to papules to vesicles and crusts over within 4-7 days. Complications can occur in immunosuppressed individuals and include pneumonia and encephalitis. Vaccination with the live attenuated varicella vaccine provides effective protection.
The document summarizes ENT manifestations of HIV infection. It describes how HIV attacks CD4 cells leading to opportunistic infections and malignancies. Common ENT issues seen include oral thrush, recurrent sinusitis, sensorineural hearing loss, and Kaposi sarcoma of the oral cavity, nose and larynx. Diagnosis involves CD4 counts and virus detection tests. Universal precautions are essential to prevent transmission among health workers.
The document summarizes several common pediatric infections and exanthematous diseases:
1) It discusses rubella (German measles), including its etiology, symptoms of a pink maculopapular rash and lymphadenopathy, and prevention through MMR vaccination.
2) It describes rubeola (measles), caused by a paramyxovirus, with symptoms of a red maculopapular rash following a prodrome of fever and upper respiratory symptoms.
3) It briefly outlines varicella (chickenpox), caused by varicella-zoster virus, presenting with a centripetal vesicular rash that is highly contagious until lesions crust over.
This document discusses various medical conditions that cause rashes or lesions in the mouth (enanthems). It provides 10 cases describing the presentation of oral rashes caused by conditions such as candidiasis, herpangina, hand-foot-and-mouth disease, herpetic gingivostomatitis, eruptive gingivitis, necrotizing gingivostomatitis, aphthous ulcers, Behcet's syndrome, and geographic tongue. It also mentions dental cysts. The document compares the clinical features of these various conditions to determine the most likely diagnosis for each case.
This document discusses cutaneous manifestations of HIV infection that can be caused directly by HIV or opportunistic infections due to immune deficiency. It classifies the manifestations into viral (such as herpes, molluscum contagiosum, EBV), fungal (candidiasis, cryptococcosis), bacterial (mycobacteria, syphilis, Staphylococcus), and parasitic (scabies, leishmaniasis). Recognizing these cutaneous signs is important for diagnosing HIV infection and providing appropriate antiretroviral therapy.
This document discusses ENT manifestations of AIDS. It begins by providing background on HIV, noting that it attacks CD4 cells. When CD4 counts fall below 200, opportunistic infections and malignancies can develop. ENT issues are then reviewed, including candidiasis, Kaposi's sarcoma, herpes zoster, Bell's palsy, sinusitis, oral thrush, hairy leukoplakia, and recurrent tonsillitis. Neck lymphadenopathy can indicate bacterial or mycobacterial infections, P. carinii, toxoplasmosis or fungal infections. Overall, the document outlines the varied ENT presentations associated with HIV/AIDS and emphasizes the need for a high index of suspicion to properly
This document summarizes information about Neisseriaceae and Bacillus species. It describes the main human pathogens in Neisseriaceae as Neisseria gonorrhoeae, which causes gonorrhea, and N. meningitidis, which causes meningitis. N. gonorrhoeae infections are highly prevalent but have low mortality, while N. meningitidis has low prevalence but high mortality. Clinical manifestations, diagnosis, treatment and control measures are discussed for both pathogens. Other genera in Neisseriaceae including Moraxella are also summarized.
The document discusses the assessment of children with recurrent chest infections. It can be a difficult diagnostic challenge to determine if a child has a simple cause like viral infections or asthma, or a more serious underlying issue like cystic fibrosis, immunodeficiency, or congenital abnormalities. A detailed history, physical exam, and selective investigations are needed to distinguish between self-limiting issues and serious progressive lung disease. Recurrent respiratory infections are common in childhood but the aim is to identify those with severe or long-term lung pathology.
Viral infection of the respiratory tract (2)Ravi Teja
The document discusses several viruses that can cause respiratory infections, including adenoviruses, respiratory syncytial virus, and parainfluenza viruses. It provides details on the structure, transmission, clinical manifestations, diagnosis, and treatment of infections caused by these viruses. Adenoviruses can cause pharyngitis, pneumonia, conjunctivitis and other syndromes. RSV is a major cause of bronchiolitis and pneumonia in infants. Parainfluenza viruses commonly cause croup in young children.
Fungal infections can be caused by yeasts, molds, or dimorphic fungi. Common fungal infections include candidiasis, dermatophyte infections, and systemic mycoses. Candida commonly causes oral and vaginal infections. Dermatophytes cause ringworm. Systemic mycoses like histoplasmosis and aspergillosis primarily affect immunocompromised individuals. Diagnosis involves microscopy, culture, antigen testing, or molecular methods. Treatment depends on the infecting fungus and severity of infection, ranging from topical antifungals to intravenous antifungals.
- Herpes simplex virus types 1 and 2 are common oral viral infections, usually transmitted via saliva or direct contact. Both viruses establish latency in ganglia. HSV-1 typically causes oral lesions while HSV-2 typically causes genital lesions.
- Varicella zoster virus causes chickenpox in children and shingles in adults via reactivation. It establishes latency in ganglia.
- Epstein-Barr virus causes infectious mononucleosis, commonly known as "mono" or "kissing disease". It is transmitted through saliva and causes fever, lymphadenopathy and pharyngitis.
Cutaneous manifestations are common in HIV patients, occurring in over 90% of cases. They can represent the first signs of HIV infection and have prognostic significance. Skin conditions in HIV patients often present atypically with lesions in unusual sites, atypical morphology, being more extensive or not responding to conventional treatments. Common manifestations include generalized rashes, oral/genital ulcers, seborrheic dermatitis, psoriasis, papulopruritic eruptions, eosinophilic folliculitis, granuloma annulare, bacterial/viral infections like herpes, fungal infections, and Kaposi sarcoma. It is important to consider HIV when patients present with rare or unusual skin
This document discusses HIV and its effects on the ENT system. It begins by explaining what HIV is and how it attacks the immune system. It then discusses the epidemiology of HIV and current global statistics. Various opportunistic infections that can affect the ENT system are described, including fungal infections of the ear, sinusitis, neoplasms like Kaposi's sarcoma, and lymphomas of the nose and oral cavity. Manifestations in different areas like the ear, nose, oral cavity and airways are summarized. Risk groups, disease progression, and treatment approaches are also briefly covered.
The document provides information on several ancient empires including the Gupta Empire, Akkadian Empire, Achaemenid Empire, Roman Empire, and Persian Empire. It discusses the origins, key rulers, and extent of these empires. The empires covered spanned different time periods from the 3rd century BC to the 4th century AD and regions including India, Mesopotamia, Persia, Europe, and the Mediterranean.
This document discusses several Microsoft Office applications like Word, Excel, and PowerPoint as well as Photoshop. It mentions using these programs to prepare for entering a new world and challenges the reader to never stop learning. The document concludes by stating that learning these tools opens up possibilities.
The role of Human Resources Management in Today's business Environmentminnoo
The document discusses the role of human resource management in business. It outlines the manager's HR responsibilities, which include recruiting, training, rewarding and evaluating employees. It also discusses attracting, developing and retaining an effective workforce. The document emphasizes the importance of employee engagement and building engagement through aspects like the work itself, rewards and organizational commitment. It provides examples of HR job duties and discusses measuring HR's contribution to organizational strategy and performance.
Maintaining Effective Workforce Partnership with Workforceminnoo
The document discusses maintaining an effective workforce. It covers several topics related to maintaining employees, including compensation, benefits, wages and salaries, and termination. The key points are:
1) Maintaining current employees involves compensation such as wages, salaries, benefits and occasional terminations. Compensation packages include both monetary and non-monetary rewards.
2) Effective compensation considers factors like internal pay equity, job evaluation, and compensation structures that fit company strategies. Benefits beyond wages are also important for attracting and retaining talent.
3) Termination policies allow dismissing poor performers while exit interviews provide feedback. Non-financial rewards like flexible schedules and meaningful work are also important aspects of maintaining an engaged workforce.
La Unión Europea ha acordado un paquete de sanciones contra Rusia por su invasión de Ucrania. Las sanciones incluyen restricciones a los bancos rusos, la prohibición de la venta de aviones y equipos a Rusia, y sanciones contra funcionarios rusos. Los líderes de la UE esperan que las sanciones aumenten la presión económica sobre Rusia y la disuadan de continuar su agresión contra Ucrania.
The document discusses motivation and leadership theories. It defines motivation as an internal drive to meet needs. Several motivation theories are outlined, including Maslow's hierarchy of needs and McClelland's theory of needs. Leadership is defined as influencing others towards goals. Different leadership styles are discussed, including directive, supportive, participative, and achievement-oriented styles. The relationship between leadership styles and situational factors like subordinate and task characteristics is also examined. Qualities of successful leaders and ways to improve leadership skills are presented.
The document discusses recruitment and selection processes. It covers topics like job analysis, recruitment sources and methods, selection methods, interviews, and induction training. Specifically, it provides details on:
1) The purpose of job analysis which is to gather job facts that are analyzed and recorded to understand job requirements.
2) Various external and internal recruitment sources and methods used to attract job applicants like advertising, employment agencies, job postings.
3) The selection process including preliminary interviews, application reviews, tests, employment interviews, references checks, and medical examinations.
4) The induction process to formally introduce and integrate new employees through training on policies, work procedures and introducing them to key people.
Performance Management and Performance Appraisalsminnoo
This document discusses performance management and performance appraisals. It defines performance as successfully accomplishing tasks through skills, knowledge and motivation. Performance management is establishing shared goals and developing employees to achieve organizational objectives. Key aspects of performance management include identifying, measuring, evaluating, improving and rewarding employee performance. Performance appraisals systematically evaluate employee performance against standards and provide feedback. They are used to provide rewards, training, determine potential and review performance. The document outlines the performance appraisal process and various appraisal techniques. It also discusses challenges in performance appraisals such as biases and ineffective practices.
Training and Development, Coaching, Mentoring, Counselingminnoo
The document discusses various aspects of training and development in human resource management. It begins by defining training as developing skills for present jobs, while development focuses on skills for future, long-term roles. It then describes analyzing training needs, planning and implementing training, and evaluating training impact. Different training approaches and their suitability are outlined. Coaching, mentoring and counseling are distinguished from training, with coaching focusing on skill development through guidance from managers, mentoring providing advice from senior colleagues, and counseling addressing psychological well-being. Overall the document provides an overview of training and development processes and functions within an organizational human resource context.
Acute pharyngitis, or sore throat, is commonly caused by viruses in 40-60% of cases. Bacteria are the cause in 5-30% of cases, with Group A streptococcus being the most common bacterial cause. The symptoms of acute pharyngitis can range from a mild sore throat to tonsillitis or strep throat. Investigations like throat cultures or rapid antigen tests are not usually needed, as they do not reliably determine the cause or change treatment. Antibiotics are generally not needed for most sore throats but are recommended for confirmed strep throat to prevent rheumatic fever and acute glomerulonephritis.
Acute respiratory tract infections (ARI) are the leading cause of morbidity and mortality in children under 5 years of age. ARI can involve both the upper and lower respiratory tract and nearly 20% of cases develop into acute lower respiratory tract infections like pneumonia. Common etiologies of upper respiratory tract infections include viruses like adenovirus, rhinoviruses, and respiratory syncytial virus, as well as bacteria such as Streptococcus pyogenes. Acute pharyngitis, retropharyngeal abscesses, peritonsillar abscesses, and croup are examples of upper respiratory tract infections discussed in the document. Accurate diagnosis and timely treatment of infections are important to prevent complications.
The document discusses various types of upper respiratory tract infections including the common cold, pharyngitis, tonsillitis, croup, epiglottitis, diphtheria, otitis media, sinusitis, and lower respiratory tract infections including pneumonia. It provides details on the causative agents, epidemiology, pathogenesis, clinical features, diagnosis, treatment and prevention of these conditions. The upper respiratory tract is defined as above the vocal cords while the lower respiratory tract is below.
- Upper respiratory tract infections (URIs) are mainly caused by viruses and include illnesses like the common cold.
- Diagnosis of URIs is usually based on clinical manifestations as laboratory tests have limited utility. A rapid strep test is recommended for those with suspected strep throat.
- Treatment focuses on symptom relief through over-the-counter medications, increased fluid intake, and rest. Antibiotics should be avoided as URIs are generally viral.
Haemophilus influenzae is a gram-negative bacterium that is a major human pathogen. Type b strains cause serious invasive diseases like meningitis in children under 5 years old. H. influenzae requires heme and NAD factors to grow in the laboratory and is susceptible to several antibiotics like ceftriaxone. A vaccine containing the H. influenzae type b capsule prevents disease.
The document summarizes meningitis, including its classification, etiology, and most common bacterial pathogens based on age and risk factors. It discusses acute bacterial meningitis caused by various bacteria like Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae, Listeria monocytogenes, Streptococcus agalactiae, and aerobic gram-negative bacilli. It also discusses aseptic meningitis and various infectious agents that can cause it like viruses, bacteria, fungi and parasites.
The tonsils are lymphoid tissue located in the throat that help the immune system. Acute tonsillitis is usually caused by viruses or bacteria like Streptococcus and is typically self-limiting. Treatment focuses on pain relief and hydration. Antibiotics may help if symptoms persist after 2-3 days. Complications are rare but include peritonsillar abscesses, which are treated with antibiotics and needle aspiration. The tonsils can also present lymphomas or cancers.
This document discusses various causes of laryngeal inflammation including infections of the vocal cords caused by viruses, bacteria, fungi, and other irritants. It describes the clinical features of different laryngeal infections such as laryngitis, epiglottitis, croup and infectious mononucleosis. The management of these conditions involves treatments such as antibiotics, steroids, intubation and vocal rest. Fungal laryngitis is also discussed and diagnosed by laryngoscopy and biopsy.
Acute respiratory tract infections (ARI) are the leading cause of morbidity and mortality in children under 5 years of age globally and in Ethiopia. ARI can involve both the upper and lower respiratory tracts. Nearly 20% of ARI cases develop into acute lower respiratory tract infections like pneumonia. Common upper respiratory tract infections include acute pharyngitis, retropharyngeal/parapharyngeal abscesses, and peritonsillar abscesses. Croup (laryngotracheobronchitis) is characterized by a barking cough, hoarseness, and inspiratory stridor in young children and results from inflammation in the upper respiratory tract sometimes spreading lower. Viruses like parainfluenza
1. A 54-year-old male presented with acute epiglottitis, which was diagnosed based on flexible laryngoscopy findings of a swollen epiglottis.
2. He was admitted and started on IV antibiotics and steroids. However, he collapsed and died shortly after admission.
3. Acute epiglottitis leads to swelling of the epiglottis and surrounding structures, which can cause rapid airway obstruction. Without treatment, it can progress to a life-threatening emergency.
Takreem Ilyas presented on diphtheria, caused by Corynebacterium diphtheriae, which produces a toxin that can cause membrane formations in the throat and on the skin. The document discussed the etiology, epidemiology, pathogenesis, clinical manifestations including respiratory and cutaneous forms, complications, diagnosis through culture and PCR, treatment including diphtheria antitoxin and antimicrobial therapy, and prevention through vaccination.
1. Measles is a highly contagious virus that infects the respiratory tract and causes symptoms like fever, cough, and a characteristic rash.
2. The introduction of the measles vaccine in 1963 led to a dramatic reduction in cases in the United States, with elimination of endemic transmission by 1993 due to high vaccination rates.
3. Complications from measles can include pneumonia, encephalitis, and a rare but severe form called subacute sclerosing panencephalitis that develops years after initial infection.
Evaluation And Management Of Upper Respiratory Tract Infections In Children Dawood Al nasser
Evaluation And Management Of Upper Respiratory Tract Infections In Children
This presentation offers helpful comparison tables, please note that some recommendation might have changed since preparation and publication of this material.
Unveiling Pharyngitis: Causes, Symptoms, Diagnosis, and Treatment Strategies.pdfNoorulainMehmood1
Pharyngitis, a common inflammatory condition of the throat, presents a significant burden on healthcare systems globally. This comprehensive review explores the multifaceted aspects of pharyngitis, encompassing its etiology, clinical manifestations, diagnostic approaches, and therapeutic interventions. Pharyngitis, often referred to as sore throat, can stem from various infectious and non-infectious causes, including viral and bacterial pathogens, environmental irritants, and underlying medical conditions. Clinical presentation typically involves symptoms such as throat pain, difficulty swallowing, fever, and swollen lymph nodes. Differential diagnosis is crucial to distinguish between viral and bacterial etiologies, with streptococcal pharyngitis being a common bacterial cause requiring specific treatment. Diagnostic modalities include clinical evaluation, throat swabs for culture or rapid antigen testing, and, in some cases, imaging studies. Treatment strategies range from supportive measures, such as rest and hydration, to antimicrobial therapy for bacterial infections. Additionally, symptomatic relief can be achieved through analgesics, antipyretics, and throat lozenges. Prevention of pharyngitis involves practicing good hygiene, avoiding exposure to respiratory pathogens, and vaccination against specific bacterial pathogens. This review provides valuable insights into the epidemiology, pathophysiology, and management of pharyngitis, aiming to optimize patient care and outcomes.
Keywords: Pharyngitis, sore throat, streptococcal pharyngitis, diagnosis, treatment, antimicrobial therapy, viral infections, bacterial infections
This document summarizes various chronic pharyngeal infections, including nonspecific chronic pharyngitis caused by smoking, irritants, and stress. It also discusses specific infections like syphilis, tuberculosis, toxoplasmosis, and candidiasis. Treatment options are provided for each infection. HIV/AIDS related head and neck presentations are also covered, such as Kaposi's sarcoma, opportunistic infections, and primary HIV infection.
Acute respiratory infections (ARI) are responsible for 20% of childhood deaths under 5 years of age, with pneumonia accounting for 90% of ARI mortality. Children under 2 years old, malnourished children, children with HIV, and those with poor access to healthcare or poorly educated parents are most at risk. ARIs are a common cause of outpatient visits (20-60%) and admissions (12-45%) in children. Common respiratory infections affecting children include the common cold, acute epiglottitis, croup, ear infections, tonsillitis, sinusitis, and pneumonia. Bacteria and viruses can cause ARIs, with symptoms and severity depending on the specific infectious agent.
This document provides information about Neisseria meningitidis, the bacteria that causes meningococcal meningitis. It describes the morphological features and virulence factors of N. meningitidis, including its gram-negative diplococcal shape, polysaccharide capsule that allows it to evade the immune system, and pili that enable it to attach to cells in the nasopharynx. The document also outlines the pathogenesis of meningococcal meningitis, noting that the bacteria spread from the nasopharynx via the bloodstream to the meninges, where it can cause inflammation and potentially fatal infection.
1) Mycotic diseases of the paranasal sinuses range from indolent infections in healthy individuals to lethal infections in immunocompromised people.
2) Fungal sinusitis is classified into invasive, noninvasive, and allergic types based on histopathology and clinical presentation. Invasive types can spread to nearby structures like the orbit and brain.
3) Diagnosis involves imaging like CT scans to assess bone destruction, biopsy and culture of tissue to confirm infection and identify the fungal species. Treatment depends on the type but may include antifungal drugs, surgery, and improving immune function.
Acute respiratory tract infections (ARI) are the leading cause of morbidity and mortality in children under 5 years of age. ARI can involve both the upper and lower respiratory tract and nearly 20% of ARI cases develop into acute lower respiratory tract infections like pneumonia. Common upper respiratory tract infections include acute pharyngitis, retropharyngeal/parapharyngeal abscesses, and peritonsillar abscesses. Croup (laryngotracheobronchitis) is characterized by a barking cough, hoarseness, and inspiratory stridor in young children, usually caused by parainfluenza virus. Management depends on severity but may include steam therapy, dexamethasone, ne
Bordetella pertussis causes whooping cough or pertussis, a serious respiratory illness. It is transmitted through airborne droplets when someone with pertussis coughs or sneezes. Pertussis typically progresses through catarrhal, paroxysmal, and convalescent phases. Treatment involves supportive care and antibiotics, with isolation of infected individuals to prevent spread. Vaccination is the most effective prevention strategy through DTaP vaccination in childhood.
Este documento presenta información sobre antibióticos y resistencia a antibióticos. Explica los mecanismos de resistencia bacteriana como la producción de betalactamasas y modificaciones en las proteínas de unión a penicilina. También describe los principales tipos de betalactamasas y los genes responsables de la resistencia encontrados comúnmente en anaerobios orales. Finalmente, presenta datos sobre la frecuencia de bacterias productoras de betalactamasas aisladas de infecciones orales.
Este documento presenta información sobre la estructura y organización de las células procariotas y eucariotas. Describe las principales características y diferencias entre estas dos clases de células, incluyendo detalles sobre el núcleo, ADN, división celular, reproducción y organelos. También incluye información sobre las estructuras y procesos metabólicos clave de las células procariotas como la membrana, peptidoglucano, ribosomas y síntesis de proteínas.
This document provides a review of methods for isolating and identifying Candida species from the oral cavity. It discusses:
1) The importance of identifying Candida species as they differ in pathogenicity and antifungal susceptibility.
2) Common techniques for isolating Candida include swabs, oral rinses, and imprint cultures. Microscopic examination and culture allow identification.
3) Culture media like Sabouraud's dextrose agar are used to isolate and identify Candida species based on colony characteristics. Chromogenic media can distinguish multiple species.
La Unión Europea ha acordado un paquete de sanciones contra Rusia por su invasión de Ucrania. Las sanciones incluyen restricciones a las transacciones con bancos rusos clave y la prohibición de la venta de aviones y equipos a Rusia. Los líderes de la UE esperan que las sanciones aumenten la presión económica sobre Rusia y la disuadan de continuar su agresión contra Ucrania.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Kat...rightmanforbloodline
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
TEST BANK For Basic and Clinical Pharmacology, 14th Edition by Bertram G. Katzung, Verified Chapters 1 - 66, Complete Newest Version.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...
Group a beta_hemolytic
1. Group A Beta-hemolytic Streptococcal Infections
Michael E. Pichichero, MD*
IMPORTANT POINTS
1. Group A streptococci cause about 15% of acute sore throats in children.
2. Group A streptococcal infection cannot be diagnosed reliably on clinical grounds; a rapid strep test or throat culture is
needed.
3. Although penicillixi G therapy for 10 days remains the gold standard, treatment of streptococcal pharyngitis for 5 days
with several kinds of cephalosporins or azithromycin is effective and has the advantage of greater compliance.
4. Recent cases of rheumatic fever in children often have occurred ¡u middle-income, suburban families.
5. Streptococcal toxic shock syndrome generally has skin and soft tissues as portals of entry, especially when secondary
infection is concurrent with varicella.
Group A beta-hemolytic streptococci (GABHS) are gram-positive bacteria that grow in culture as pairs or chains of variable
length. On sheep blood agar they appear as transparent to opaque round, small colonies surrounded by a zone of complete
hemolysis (beta) of red cells. The beta-hemolytic streptococci include the pathogens of Lancefield groups A. C, and G. In
contrast, viridans streptococci produce partial (alpha) or no (gamma) hemolysis. Group D streptococci produce variable
hemolysis, and S pneumoniae (pneumococcus) produce alpha-hemolysis.
Biologic products elaborated by GABHS are important determinants of virulence. Antibody responses to these antigens
sometimes are used to identify these bacteria as the cause of an infection. In addition to hemolysins (including streptolysins
O and S), GABHS may elaborate streptokinase, streptodornase bacteriocins, deoxyribonuclease, exotoxins, hyaluronidase,
nicotinamide adenine dinucleotidase, and proteinase.
Types of Group A
Streptococcal Infections
UPPER RESPIRATORY
TRACT INFECTIONS
GABHS causes many types of infection in children (Table 1). Tonsillopharyngitis is by far the most common manifestation
in the pediatric population; it will be discussed at length later in this review. Most cases of bacterial otitis media and
sinusitis are caused by S pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis; GABHS accounts for 5% to
10% of cases and, therefore, must be considered as a possible pathogen in these conditions. The history of acute otitis media
generally includes acute ear pain, often associated with fever, diminished hearing, and cough. Pneumatic otoscopy should
be employed on physical examination. The findings of a red, bulging tympanic membrane and purulent material in the
middle ear space are seen more frequently with pneumococcal or GABHS Otitis media. Otitis media caused by H influenzae
and M catarrhalis is more likely to produce a thickened-appearing tympanic membrane That has less erythema and a
grayish exudate in the middle ear space. However these distinctions on clinical examination are far from universal and
cannot be relied upon to direct therapy.
2. LOWER RESPIRATORY TRACT INFECTIONS
GABHS can cause lobar pneumonia. Affected children generally have high fevers and appear quite toxic. Empyema occurs
more commonly than with pneumococcal pneumonia which is a more common bacteria] cause of lobar pneumonia.
SKIN INFECTIONS
The most common skin and soft tissue infection caused by GABHS is impetigo. Typically, a small pustule develops at the
site of a previous injury, such as a scratch. abrasion or insect bite, then ruptures spontaneously and develops a thin, honey-
colored scab. Multiple sites of involvement result from scratching. The individual lesions are very superficial and involve
the outermost layers of the epidermis. The streptococci causing impetigo or pyoderma may be found in the nose at throat,
but this infection usually occurs after the skin infection has been established. Impetigo generally occurs during summer
months.
Erysipelas is a superficial cellulitis characterized by a raised irregular, advancing border. Systemic symptoms include
fever, vomiting, and irritability. GABHS may be the only causative organism or may be present with Staphylococcus
aureus, as in other forms of cellulitis. There are no clinical features unique to skin and soft-tissue infections caused by
GABHS as compared with those caused by S aureus; this, both organisms should be considered.
CARDIOVASCULAR, MUSCULOSKELETAL, AND LYMPHATIC LNFECTIONS
GABHS accounts for a small percentage of cases of endocarditis (more commonly due to viridans streptococci and group D
streptococci) myocarditis and pericarditis (more commonly due to viruses), and phlebitis (more commonly due to S aureus).
GABHS is the second most common bacteria] cause of musculoskeletal infections and lymphadenitis following S aureus.
Necrotizing fasciitis is discussed later as a GABHS complication. Genera]ly when GABHS is the cause of cardiovascular,
musculo-skeletal, or lymphatic infections illness progresses rapidly and is marked by high fever and systemic toxicity.
3. BACTEREMIA AND MENINGITIS
The blood stream or meninges rarely are invaded following infection of the upper respiratory tract or skin with GABHS. An
increased incidence of invasive streptococcal infection is observed in certain vulnerable host conditions (eg, post-
splenectomy, sickle cell disease, varicella, or immunodeficiency). Signs and symptoms of streptococcal bacteremia and/or
meningitis do not differ notably from these infections caused by other bacteria, which are more common pathogens.
Tonsillopharyngitis
EPIDEMIOLOGY
GXBHS throat infections produce a self-limited, localized inflammation of the tonsillopharynx that generally lasts 3 to 5
days. Antibiotic treatment if prompt and appropriate shortens the duration of symptoms and the period of contagion and
reduces the occurrence of localized spread and suppurative complications. A major objective of antibiotic therapy is to
prevent rheumatic fever and possibly reduce the incidence of poststreptococcal glometrulonephritis.
Humans are the natural reservoir for GABHS, and infections are spread person to person. The nasopharynx and
oropharynx are the primary carriage sites for this organism; the skin and anus also are potential sites. Direct contact with
infected nasopharyngeal or oropharyngeal mucosa and with contaminated objects such as toothbrushes is of less
importance. Rarely, food is a vehicle for the spread of GABHS.
Spread of GABHS requires a susceptible host and is facilitated by close contact. Infection rarely is acquired in infancy,
probably because of maternal immunity conferred transplacentally. Infection is uncommon in those younger than 2 years of
age, possibly due to decreased attachment of GABHS
to nasopharyngeal and oropharyngeal epithelial cells.
When infection occurs in toddlers, it most often
involves the nasopharynx or skin (impetigo). Close
contact with a large number of individuals who
potential]y are infected with GABHS, as occurs in
child care and grade school, results in more frequent
spread of illness. Adolescents usually have had contact
with the organism over time, which provides
immunity, thereby rendering GABHS infections less
common in this population. The frequency of isolation
of GABHS and other tonsillopharyngeal pathogens in
children and adolescents is shown in Table 2.
DIFFERENTIAL DIAGNOSIS
The largest proportion (15% to 40%) of children and
4. young adults (30% to 60%) who have tonsillopharyngitis have viral infections. About 8% to 40% of children and 5% to 9%
of adolescents who have sore throat, fever, and tonsillopharyngeal inflammation have GABHS infection. Other bacteria
infrequently cause throat infection. The differential diagnosis of GAB HS tonsillopharyngitis, particularly among
adolescents, should include infection caused by group C and G Streptococcus sp and Neisseria gonorrhoeae. Anaerobes
may be involved in deep-seated infections such as peritonsillar or retropharyngeal abscesses, but there is no evidence that
surface colonization with these organisms causes symptomatic tonsillopharyngitis.
Mycoplasma pneumoniae, Chlamydia pneumoniae (TWAR agent), and Arcanobacieriwn haemolyticum are occasional
causative agents of symptomatic tonsillopharyngitis[ Corynebacterium diphtheriae remains a cause of tonsillopharyngitis in
developing countries. Sore throats often are “idiopathic” in etiology. It is not clear whether these cases of tonsillopharyngitis
actually are caused by viruses that at present cannot be identified or whether they are dime to other factors such as postnasal
drip or allergy.
CLINICAL MANIFESTATIONS
GABHS tonsillopharyngitis cannot be diagnosed on clinical grounds in most patients. The patient who has a classic
GABHS throat infection exhibits fever, tonsillopharyngeal erythema and exudate, swollen and tender anterior cervical
adenopathy, absence of rhinorrhea and cough, and an elevated white blood cell count during mid-winter to early spring
(Table 3). When this constellation of symptoms is present, the likelihood of GABHS infection approaches 60% to 70% in
children and 20% to 30% in adolescents.
Symptoms of groups C and G streptococcal pharyngitis are similar to those of GABHS. Adolescents and young adults
are particularly susceptible to groups C and G streptococcal pharyngitis. The symptoms may not be as severe as those asso-
ciated with GABHS infection, but all may be present.
After screening more than 20,000 children who had cute respiratory illnesses associated with sore throat. Breese derived
a nine-factor scoring system for diagnosing GABHS tonsillopharyngitis. Children who had fewer than 25 points in the
Breese scoring system had a 6% probability of having GABHS tonsillopharyngitis; this represented 20% of the children
from whom throat cultures were obtained. Children who scored 26 to 31 points had a probability of approximately 40% and
represented 36% of the study population. Children who had 32 to 38 points had a probability of 84% and represented 44%
of the study population. The Breese scoring system requires a white blood cell count from every patient; eliminating this
finding invalidates the applicability of the scoring.
The accuracy of probability estimates for diagnosing GABHS tonsillopharyngitis made by experienced physicians has
been assessed in a university health service among an adolescent population. When two general internists, three pediatri-
cians, and five family physicians predicted the culture outcome on clinical grounds for 308 patients who had sore throat, the
probability of positive GABHS culture was overestimated for 81% of patients. Only 15 cultures (4.9%) were positive for
GABHS. Over diagnosis almost always led to the decision to treat with antibiotics.
Based on these carefully conducted studies, it would appear that the clinical diagnosis of GABHS throat infections is
unreliable in most patients. A subset of children (approximately 20%) and adolescents (approximately 67%) will present
with sore throat and few other symptoms or signs of GABHS tonsillopharyngitis; they require neither a diagnostic test
(culture or rapid antigen detection) nor treatment. The sore throat is pan of a viral upper respiratory tract infection. These
individuals can be distinguished clinically from other patients by an accompanying rhinorrhea, cough, hoarseness, and often
5. an absence of fever, tonsillopharyngeal erythema or exudate, and cervical lymphadenitis.
LABORATORY TESTING
Throat Culture
Breese and Disney were the first to report the use of throat cultures plated un sheep
blood agar in an office in 1954. The use of a throat culture to confirm the presence of
GABHS has become a common pediatric practice: by the early 1980s, the Centers for
Disease Control and Prevention estimated that 28 to 36 million throat cultures were
performed annually in the United States. Ibis simple laboratory test is valuable in
avoiding unnecessary antibiotic therapy and in identifying patients who require
treatment.
False-positive Throat Cultures
False-positive GABHS throat cultures usually occur through misidentification of
beta-hemolytic streptococci belonging to Lancefield groups B, C, F, or G, or betahemolytic S aureus. The bacitracin
sensitivity test can differentiate GABHS from non-GABHS betahemolytic strains; 95% to 100% of GABHS demonstrate
a zone of growth inhibition around a disk containing 0.04 units of bacitracin compared with 83% to 97% of non-GABHS
that do nut. If there are sufficient numbers of bacteria in the area of the disk, the test can be interpreted adequately on a
primary blood agar plate.
False-negative Throat Cultures
Explanations fur false-negative throat cultures include: 1) faulty culture technique, 2) surreptitious antibiotic use, and 3)
faulty bacteriologic methods. The optimal site fur throat culture is the surface of the tonsil. The tongue, hard palate, teeth,
and buccal mucosa are not satisfactory. It is difficult to isolate GABHS after one or two doses of antibiotic have been
administered, and occult antibiotic use may be a significant cause of false-negative throat cultures. Patients frequently do
not take the full amount of prescribed antibiotic, and leftover drug is saved for the next occurrence of similar symptoms.
In a hospital emergency department study, 10% of patients who forthrightly denied antibiotic use on direct questioning by
a physician had evidence of antibiotics detected in their urine.
Quality assurance methods should be incorporated into laboratory routines and now are mandated by CLIA
regulations. A known isolate of GABHS should be inoculated daily onto a plate and incubated concurrently as a positive
control with other throat swab cultures obtained from patients suspected of having GABHS infection. Duplicate throat
swabs should be processed in a reference laboratory (hospital) periodically to corroborate office laboratory results.
Rapid GABHS Antigen
Detection Tests
GABHS antigen detection tests can be performed quickly in a physician’s office or clinic at a cost that is comparable to a
10-day prescription of penicillin. These tests rely un extraction of carbohydrate antigen of GABHS followed by detection
with an antibody-tagged reagent that produces a clumping effect or color change after interaction. If properly performed,
the sensitivity (average, 76% to 87%) and specificity (ayera2e, 90% to 96%) of rapid antigen detection testing can
approach that of throat cultures (Table 4).
One recommended strategy for use of the rapid GABHS antigen test is to deem a positive result as reliable, with treatment
6. rendered as appropriate. In contrast, a negative rapid antigen detection test result suggests no need for treatment, but
consideration of sending a throat swab for confirmatory culture to avoid missing an infection that might require therapy.
It should be recognized that this strategy could result in over treatment of about one third of patients who have positive
tests , given the positive predictive value of the test because GABHS prevalence is about 15% in the winter respiratory
infection season. Moreover, confirmatory cultures in those who have negative results to rapid tests will be positive in only
1.5% to 3.4% of patients if the prevalence of GABHS is 8% to 15%, respectively. The test is most effective when iris
performed in immediate proximity to where patients are seen and the charge to patients should be modest so as not to dis-
courage its use. Such availability allows the integration of rapid GABHS antigen detection testing into clinical decision-
making, despite the busy flow of patients in all types of settings. Rapid GABHS antigen testing does not require the
expertise of a certified microbiologist or laboratory technician; it can be performed by any properly trained physician; nurse,
or allied health professional. It is essential that those performing the tests review the package insert carefully to comply
fully with the instructions. Shortcuts and lack of attention to detail reduce the sensitivity and specificity of these tests
ANTIBIOTIC SUSCEPTIBILITY GABHS are highly susceptible o penicillins and cephalosporins. In vivo activity of these
drugs is influenced significantly by the level of antibiotic achieved at the site of infection. Antibiotics may have variable
rates of absorption, absorption can be influenced by food, or their action may be compromised by enzymatic breakdown or
other microbial resistance mechanisms. GABHS usually are susceptible to erythromycin, clarithromycin, azithrornycin,
Lincomycin, and clindamycin. However, GABHS resistance to the macrolides occurs and may develop in a community or
country as a consequence of antibiotic pressure from their extensive use. Cross-resistance among macrolides is observed.
The minimal inhibitory concentration (MIC) of the aminoglycosides. sulfonamides, chloramphenicol, and tetracycline
against most GABHS strains is consistent with the clinical observation that these agents are of limited value in the treatment
of such infections. Sulfadiazine is acceptable for secondary prophylaxis in rheumatic fever. This reflects the difference
between antibiotic efficacy when bacterial colonization first begins (prophylactic drugs might be effective) versus when
active infection is established (agents effective in treatment are required).
ANTIBIOTIC TOLERANCE
GABHS tolerance to penicillin has been studied extensively in the laboratory and clinically over the past decade. A ratio of
7. the MIC to the minimum bactericidal concentration (MBC) of 32-fold or greater defines a tolerant strain, which is inhibited
but non killed by penicillin. Whereas a clear correlation between antibiotic tolerance and clinical treatment failures has been
demonstrated for S aureus, there is no such correlation for GABHS. Clinical observations of tolerant GABHS strains have
involved outbreaks in which penicillin-tolerant strains resulted in penicillin treatment failures and penicillin-tolerant and
susceptible strains were associated with equivalent penicillin treatment failure rates.
TISSUE AND BLOOD LEVELS
For beta-lactam antibiotics (penicillin and the cephalosporins), the time during which the antibiotic is above the MIC is
much more important than the height of the peak antibiotic concentration in producing efficacy; this is termed “time--
dependent” as compared with “concentration-dependent” antibiotic killing. Increasing blood levels of beta-lactam
antibiotics by administering probenecid concurrently or adding procaine penicillin to benzathine penicillin does non
produce better bacteriologic efficacy Once a concentration of a betalactam antibiotic has been reached that ensures activity
at the bacterial cell wall, increased drug concentrations do not eradicate GABHS more effectively.
Beta-lactam antibiotics work against actively growing bacteria. After initial bactericidal activity, there is a time span of
treatment before active bacterial growth resumes during which the antibiotic -is non essential. Ibis makes intermittent oral
therapy feasible as an alternative to the continuous levels of antibiotics achieved with injectable benzathine penicillin G.
DURATION OF THERAPY
injections of benzathine penicillin provide bactericidal levels against GABHS for 21 no 28 days. The addition of procaine
alleviates some of the discomfort associated with benzathine injections and may influence the initial clinical response
favorably GABHS is eradicated through the sustained levels of penicillin achieved with the benzathine formulation. Ten
days of penicillin treatment is required no achieve a maximum bacteriologic cure rate in GABHS tonsillopharyngitis: 5 no 7
days therapy with injectable or oral penicillin does not produce maximal GABHS eradication.
Because compliance with 10 days of therapy often can be problematic, a shorter course of
Therapy is attractive. A regimen of 4 to 5 days of therapy with several cephalosporins-cefadroxil, cefuroxime axetil,
cefpodoxime proxetil and cefdinir has been shown to produce a bacteriologic eradication rate similar or superior to that
achieved with 10 days of oral penicillin V. Cefpodoxime proxetil has been approved by the United States Food and Drug
Administration as a 5-day therapy for throat infections caused by GABHS. Azithromycin may be administered for 5 days no
treat GABHS because it persists in tonsillopharyngeal tissues form approximately 10 days after discontinuation of the drug
(total of 15 days therapy). If bacteriologic eradication is the primary measure of effective GABHS treatment, as the only
corollary for the prevention of acute rheumatic fever, then superior bacteriologic eradication with a short course of
cephalosporin or azithromycin therapy with which patients comply may prove to be a significant advance.
SYMPTOMATIC RESPONSE TO ANTIBIOTIC THERAPY
The primary reason that patients seek antibiotic therapy for sore throat is to quell symptoms and shorten the clinical course
of illness. For many years it was thought that antibiotics only minimally ameliorated the symptoms of GABHS
tonsillopharyngitis. In the 1980s this tenet was refuted by several double-blind evaluations that showed greater clinical
8. improvement in patients receiving penicillin compared with those receiving a placebo. One study showed that penicillin
relieves symptoms of GABHS tonsillopharyngitis faster and more effectively than acetaminophen.
Although antibiotics do alleviate symptoms of GABHS tonsillopharyngitis, nearly all patients will improve spontaneously,
even without treatment. The natural course of GABHS tonsillopharyngitis is a rapid onset of symptoms and signs of
infection followed by spontaneous resolution within 2 to 5 days. Thus, patients who seek care after they have had a sore
throat for more than 1 week usually do non have GABHS tonsillopharyngitis. It is non the spontaneous resolution of
symptoms, but the persistence of the organism in the tonsillopharynx that sets the stage for ongoing contagion and the risk
of acute rheumatic fever (ARF). Even though the patient feels better, persistence of the organism elicits an ongoing immune
response. If the strain is rheumatogenic and the host genetically predisposed, then ARF may follow.
If the patient has GABHS tons tonsillopharyngitis, clinical improvement should occur promptly following the start of
antibiotic therapy; failure no improve usually indicates that GABHS is non the cause of the tonsillopharyngeal infection.
GABHS is either non present or it is present bun the patient is only a carrier. The symptom-relieving effects of therapy are
most marked if treatment is instituted early in the course of illness. If therapy is started after the first 24 no 48 hours of
illness, symptoms and signs of GABHS tonsillopharyngitis may non disappear significantly more rapidly than with no
treatment.
Prompt treatment is non vital to preventing rheumatic fever. A study of military recruits in the 1950s documented that ARE
can be prevented even if treatment is delayed for 9 days after onset of symptoms of GAIBHS tonsillopharyngitis. Thus,
even after the acute symptoms of GABHS tonsillopharyngitis have subsided. ARF can be prevented. This observation is in
contrast to results with sulfadiazine treatment, which favorably influences acute symptoms when administered early in the
course of illness but does non eradicate GABHS from the respiratory tract and does non prevent ARE.
CONTAGION
The transmission rate of GABHS is approximately 35% within a family or school if the patient 15 untreated. Appropriate,
effective antibiotic treatment prevents transmission no others who are susceptible. Penicillin renders an infected individual
minimally contagious to others in approximately 24 hours. The duration of contagion when alternative antibiotics are used
has non been studied systematically. If penicillin is discontinued after 3 days of therapy, there is a 50% likelihood that the
patient will relapse with a positive GABHS infection (which may be asymptomanic). If the penicillin is stopped after 6 no 7
days of treatment, the likelihood of GABHS recurring is approximately 34%. Untreated, the spontaneous rate of
disappearance
of GABHS from the throat (by host immunity) is 50% within 1 month of acute infection.
PREVENTION OF RHEUMATIC FEVER
The efficacy of penicillin for the primary prevention of ARF was established in the early 1950s. In these seminal studies,
military recruits who had GABHS tonsillopharyngitis were given injectable penicillin G mixed in peanut Oil or sesame oil
and 2% aluminum monostearate. Injection schedules that provided at least 9 to 11 days of effective penicillin therapy
optimized GABHS eradication and the primary prevention of ARE.
BENZATHINE PENICILLIN G
A preparation of injectable penicillin was developed that combined the long-acting effect of benzathine with procaine
9. penicillin, a drug that diminishes pain at the injection site. A combination of 900,000 U of benzathine penicillin G plus
300,000 U of procaine penicillin is the preferred product for most school-age children.
ORAL PENICILLIN V
Following the determination that GABHS eradication by penicillin prevented ARE, acceptable treatment of GABHS
tonsillopharyngitis was evaluated on the basis of bacteriologic eradication. It often is forgotten or widely unknown that oral
penicillin never was shown in a prospective controlled trial no prevent ARF. The logical presumption applied no treatment
of GABHS tonsillopharyngitis has been no equate bacteriologic elimination of the pathogen from the tonsillopharynx with
likely prevention of ARF. The low incidence of ARF among patients given oral penicillin appears no validate this
hypothesis.
Various dosing regimens of oral penicillin G and V have been assessed. A daily dose of 500 no 1.000 mg of penicillin V is
preferable. Lower doses are associated with lower eradication rates, and higher doses are non beneficial. Twice-daily dosing
with oral penicillin y may be adequate therapy for GABHS tonsillopharyngitis, but once-daily treatment is not.
AMOXICILLIN, AMOXICILLIN/
CLAVULANATE, NAFCILLIN,
CLOXACILLIN, AND
DICLOXACLLLIN
Orally administered ampicillin and amoxicillin are equivalent but not superior to penicillin in eradicating GABHS from the
tonsillopharynx. Amoxicillin is more effective than penicillin against the common pathogens than cause otitis media, which
occurs concurrently with GABHS tonsillopharyngitis in up no 15% of pediatric patients. Children younger than 4 years of
age have a higher incidence of concurrent otitis media when they contract GABHS tonsillopharyngitis. Two-other features
of amoxicillin therapy may be important: 1) it tastes better than oral penicillin in suspension formulation, which can
enhance compliance for children, and 2) a recent study showed that a 6-day regimen of amoxicillin was equivalent no 10
days of penicillin therapy in eradicating GABHS from the throat.
In most comparative studies of the treatment of GABHS tonsillopharyngitis, amoxicillin/clavulanate exhibited superior
bacteriologic eradication oven penicillin. Amoxicillin is bactericidal against GABHS and clavulanate is a potent inhibitor of
bena-lactamase. Thus, amoxicillin clavulanate would be effective if copathogens were colonizing the tonsillopharynx
(discussed below). Cloxacillin and dicloxacillin are adequate therapy for GABHS eradication, bun oral nafcillin is non.
ERYTHROMYCIN, CLARITHROMYCIN, AND AZITHROMYCIN
For patients allergic to penicillin, a macrolide antibiotic (eg, erythromycin) is the suggested antibiotic for GABHS
tonsillopharyngitis. Erythtomycin estolate and ethylsuccinate have been shown consistently no compare more favorably
with oral penicillin in bacteriologic eradication than erythromycin base or stearate. Dosing frequency studies with various
erythromycin preparations have shown that administration two, three, or four times daily produces equivalent bacteriologic
eradication rates.
Clarithtromycin has eradicated GABHS causing tonsillopharyngitis at a rate similar or superior no penicillin. Azithromycin
10. has been evaluated for treatment of GABHS tonsillopharyngitis in 3- and 5-day regimens. The 5-day course of treatment
proved as effective or more effective than penicillin in eliminating GABHS from the throat. -A 3-day treatment course with
azithtomycin for GABHS tonsillopharyngitis has been approved by regulatory agencies outside the United States, but two
recent studies suggest that 3 days is inadequate for optimal efficacy. The regimen for azithtomycin in the treatment of
GABHS tonsillopharyngitis in the United States is 10 no 12 mg/kg per day for 5 days, which differs from the dosing
recommended for acute otitis media. The 5-day dosing regimen usually requires the purchase of two bottles of medication,
which increases the cost. Both azinhtomycin and clarithtomycin produce fewer gastrointestinal side effects than does
erythromycin.
CLINDAMYCIN, LINCOMYCIN, AND RIFAMPIN
Clindamycin and lincomycin have been evaluated as primary treatment for GABHS tonsillopharyngitis. Clindamycin is
effective in eliminating carriage of GABHS, but its routine use is non advocated for GABHS tonsillopharyngitis because of
conicern for infrequent but significant side effects, including pseudo membranous colitis. Rifampin has been studied in
combination with oral penicillin as a potential antibiotic for eradicating carriage of GABHS, and successful results have
been observed.
CEPHALOSPORINS
Oral cephalosporins have been studied as alternative antibiotics for the treatment of GABHS tonsillopharyngitis since 1969.
Consistently superior bacteriologic eradication rates, and in many cases clinical cure rates, have been observed with the
cephalosporins compared with penicillin. In 1991, a meta-analysis was published comparing the bacteriologic and clinical
cure rates achieved with various cephalosponins and various penicillin preparations. Nineteen studies of adequate study
design and implementation were analyzed. The mean bacteriologic failure rare under these ideal study conditions was
significantly higher in patients treated with penicillin (16%) than in those treated with cephalosporins (8%, P <0.001). The
mean clinical failure rate also was evaluated by meta analysis and documented as 11% with various penicillin formulations
and 5% with the cephalosporins (P <0.001). Although the methodology of this meta-analysis has been questioned and the
Red Book states that additional studies are warranted, numerous subsequent large prospective, double-blind, randomized
initials comparing first-, second-, and third generation cephalosporins have confirmed the meta-analysis results. The
superiority of cephalosporins in GABHS eradication form the throat now appears no be established. The current debate
focuses on their cost effectiveness compared with penicillin or amoxicillin given the magnitude of the difference in the
anticipated efficacy rates. There also is concern about possible widespread empiric use of these valuable, broader spectrum
agents for all sore throats rather than only for laboratory-confirmed GABHS cases.
CHANGES IN PENICILLIN TREATMENT SUCCESS
Penicillin treatment failure rates raiigingftoms%to35%for GABHS tonsillopharyngitis have been reported in various studies
oven the past 30 years; an increase in such failures has been noted in the past decade. This increase could be reflected in a
rise in the incidence of ARF, which has non been observed consistently. However, declining efficacy of penicillin (and
11. other antibiotics) may not necessary manifest as an increased incidence in ARE because treatment failure must occur in the
presence of a rheumatogenic GABHS strain and as yet undetermined specific host susceptibility factors.
Recent descriptions of GABHS toxic shock syndrome and GABHS mediated necrotizing fasciitis have raised concerns that
a resurgence of virulent GABHS infections may be occurring. Penicillin treatment failure has been noted among patients
expeniencing severe GABHS infections. Although the site of infection usually is cutaneous for these severe infections, the
tonsillopharynx has been the source in some cases. These penicillin failures may be due to the “Eagle” effect in which
virulent, toxin-producing strains of GABHS divide rapidly, reach a stationary phase of growth (perhaps as a consequence of
diminished nutrients in the immediate environment of the infection), and resist the bactericidal activity of penicillin and
other beta-lactams while in this phase. Antibiotics that inhibit bacterial protein synthesis, such as clindamycin have proven
useful in eradicating such GABHS strains.
Explanations for Antibiotic Failure
DEFICIENCIES IN ANTIBIOTIC FORMULATIONS
The quality of benzathine penicillin G may not be uniform among various manufacturers un various- countries. Benzanhine
penicillin G preparations that produce lower, variable, and a shorter duration of adequate levels have been described
COMPLIANCE
For optimal absorption, oral penicillin V should be administered 1hour before or 2 hours after meals. Recommended thrice
daily dosing of penicillin that must be administered away from meal time can prescnn a formidable bamer no compliance.
Reducing the number of times a day that a patient must take any medication and making it possible no take doses with
meals will improve patient compliance. Three nines daily dosing typically is associated with a 30% no 50% compliance rate
compared with 70% no 90% compliance with once or twice daily dosing schedules. Intramuscular benzanhine penicillin
injections obviate issues of compliance.
Good-tasting suspension formulations of oral antibiotics can enhance compliance among children. In contrast, a marginal
or poor taste may lead to the child refusing, spitting out, or vomiting the drug. Penicillin V suspension does not have a good
taste, but most children find the taste of amoxicillin quite pleasant. Perhaps this is why amoxicillin is prescribed for
tonsillopharyngitis more frequently by physicians in the United States that is penicillin. Taste comparisons of antibiotic
suspensions have found several cephalosporins to taste best.
Patients’ perceptions of antimicrobial side effects strongly influence compliance. All of the antibiotics commonly employed
no treat GABHS tonsillopharyngitis are notable for their low incidence of adverse effects. Rash and gastrointestinal upset
occur in 1% 10 2% of patients who receive the penicillins and cephalosporins, Macrolides, particularly erythromycin, more
frequently produce gastrointestinal upset. Amoxicillin/clavulanate is associated with a higher incidence of diarrhea than
other agents.
REPEATED EXPOSURE
Crowded living conditions encourage the transmission of GABHS within the family, an work, at school, or in child care
settings. A recurrence of GABHS tonsillopharyngitis after treatment that involves the same serotype may be associated with
milder symptoms. These individuals are contagious no others in their environment and are susceptible no rheumatic fever.
12. EARLY TREATMET SUPPRESSES IMMUNITY
Prompt initiation of antibiotic treatment with the onset of acute symptoms may suppress the increases in antistreptolysin O
(ASO) and antiDNase B antibody that typically follow GABHS infections. Antibody suppression has been associated with
relapse and recurrence of GABHS tonsillopharyngitis. Although delaying treatment probably is not necessary in most cases,
it may be useful for patients who have frequent recurrent, mild-to-moderate infections. Delaying treatment for 2 or 3 days
(maximum of 9 days from onset of symptoms) may allow the patient’s natural immunity to develop without risk of
rheumatic fever. Such a strategy should not be considered if the patient is toxic or severely in or if highly virulent or
rheumatogenic strains are circulating in a community.
COPATHOGENS
The presence of co-colonizing bacteria in the throat, termed copathogens, that elaborate beta-lactamase in the
tonsillopharynx has been proposed as a possible mechanism by which penicillin is inactivated in vivo prior to bactericidal
action on GABHS. S. aureus, H influenza, M catarrhalis and beta-lactamase-producing anaerobic species are common flora
in the tonsillopharynx. The prevalence of these beta-lactamase-producing bacteria may increase as a consequence of
penicillin treatment of patients who have GABHS tonsillopharyngitis. This recent penicillin threatening may predispose
some patients to harbor higher numbers o beta-lactamase-producin copathogens, which in turn may lead to increased rates
of penicillin treatment failure.
Indirect evidence suggests that when copathogens are present in the tonsillopharynx, use of antibiotics that are effective
despite the presence of beta-lactamase may enhance bacteriologic and clinical success, but this is not a universal finding. It
is not necessary to eradicate the copathogens that produce betalactamase. Rather, the antibiotic employed must remain
active despite the presence of beta -lactamase in vivo.
STREPTOCOCCAL CARIUAGE
GABHS carriage is likely when GABHS is documented in the throat but the patient shows neither symptoms of
tonsillopharyngitis nor a demonstrable rise in streptococcal antibody titers. This operational definition is complicated by
early initiation of antibiotic therapy that may prevent an antibody response following GABHS infection. The absence of an
antibody response, therefore, does not rule out a bona fide GABHS infection if treatment has been rendered. Also, patients
experiencing a relapse with the same strain of GAB 1-LS (a homologous serotype) soon after a primary infection often have
milder symptoms of GABHS infection. These symptoms may be recalled only on direct questioning. Such patients have
been shown to demonstrate a rise in antibody, which identifies them as susceptible to ARF.
Whether treated or untreated symptoms of acute GABHS infection eventually resolve, but carriage of the bacteria may
persist. In the early stages of this carrier state, patients are contagious to others. After 1 to 2 months, the carrier state is
associated with diminished numbers of GABHS organisms in the tonsillopharynx, reduced bacterial virulence, and less
transmissibility to others. The presence of GABHS on throat culture or as detected through rapid diagnostic testing does not
distinguish between the patient who has bona fide GABHS tonsillopharyngitis and is at risk for ARF and the patient who
has an acute viral sore throat and is only a GABHS carrier. Asymptomatic GABHS carriage may persist despite intensive
antibiotic treatment and may account for apparent penicillin failures because eradication of the GABHS carrier state
13. generally cannot be achieved with penicillin.
Disadvantages and Advantages of Penicillin Alternatives
Penicillin (not amoxicillin) currently is recommended as first-line therapy for GABHS infections by the American Academy
of Pediatrics Red Book Committee and the American Heart Association. Erythromycin is recommended as the alternative in
those allergic to penicillin. Increase use of empiric broad-spectrum antibiotic therapy for treatment of sore throat with newer
macrolides, cephalosporins or amoxicillin/clavulanate has the potential for exacerbating the escalating problem of antibiotic
resistance among respiratory pathogens.
Alternatives to penicillin for the treatment of GABHS tonsillopharyngitis are five to ten times more expensive, ranging from
approximately $30 to $60 for a l0-day treatment course. The differing bacteriologic cure rates of antibiotic therapy must be
viewed in light of the different antibiotic costs. If enhanced bacteriologic eradication can be achieved with a more expensive
agent and the enhanced eradication results in a reduction in illness burden, recurrence rates, physician visits. laboratory
tests, morbidity and/or mortality (direct costs). and loss of school for children and work for parents (indirect costs), then the
difference in antibiotic cost may be small compared with the overall cost of failed therapy. For example, in the subset of
patients who have recently experienced a penicillin treatment failure for GABHS tonsillopharyngitis, a cost-effectiveness
analysis has shown that follow-up treatment with cefadroxil is less costly than re-treatment with penicillin. In that study,
antibiotic acquisition costs represented about 5% (for penicillin) to 15% (for cefadroxil) of the total cost of treatment, with
the remainder attributable to direct and indirect costs. Cephalosporins appeared more cost-effective because the higher cure
rate resulted in lower overall costs.
Complications
RHEUMATIC FEVER
Rheumatic fever is a
nonsuppurative sequela of
infections with GABHS. There has
been a steady and dramatic decline
in its incidence in the United States
since the beginning of this century.
The decrease in incidence occurred
before the antibiotic era and, thus,
has been attributed largely to
improving socioeconomic
conditions and better access to
medical care. A shift from rheu-
matogenic to nonrheumatogenic
strains circulating in the United
States also may be a major con-
tributing factor.
Focal outbreaks of rheumatic fever occurred in the United States during the time span of 1984 through 1989 in Salt Lake
14. City, Utah; Columbus and Akron, Ohio; Pittsburgh, Pennsylvania; Nashville and Memphis, Tennessee; and among military
recruits in training centers in California and Missouri. Epidemiologic features of these outbreaks are presented in Table 6. A
particularly striking feature of these episodes was their occurrence in predominantly middle-income families as opposed to
patients in urban, lower socioeconomic environments. The major manifestations of ARF are carditis, arthritis, chorea,
erythema marginatum, and subcutaneous nodules. Minor manifestations include arthralgia, fever, laboratory documentation
of GABHS infection, elevated erythrocyte sedimentation rate or C-reactive protein levels, and prolonged P-R interval on
electrocardiography.
STREPTOCOCCAL TOXIC SHOCK SYNDROME
Since the mid-l980s there has been a resurgence of severe and even fatal acute GABHS infections. A toxic shock syndrome
has been described in association with soft tissue infections that resembles staphylococcal toxic shock syndrome. The
clinical characteristics included profound hypotension, shock, and multiorgan system failure (Table 7). An increased
prevalence of virulent toxin-producing GABHS serotypes, along with diminished host immunity because of the low
prevalence of these serotypes in preceding years, seems to have contributed to this increase in severe GABHS infections.
Pre-existing varicella infections have been noted in 40% to 50% of case reports of severe, invasive GABHS disease in
children. Notable laboratory features of the streptococcal toxic shock syndrome include a depression of the white blood cell
count, with a preponderance of immature granulocytes. Thrombocytopenia, hypocalcemia, and hypoalbuminemia also are
observed frequently. Patients suspected of experiencing streptococcal toxic shock syndrome should have serum creatinine
and creatinine kinase blood levels measured; elevations in these laboratory parameters have been noted frequently with this
condition due to associated necrotizing fasciitis.
POSTSTREPTOCOCCAL
GLOMERULONEPHRITIS
Poststreptococcal g1om~rulonephritis is the
most common form of glomerulonephritis in
children; it is primarily a disease of preschool
and school-age children. It follows either an
upper respiratory tract or skin infection due to
GABHS, but it is far more common after an
infection of the throat. Just as there are apparent
rheumatogenic strain, so too are there
nephritogenic strains of streptococci. The
principal clinical findings of poststreptococcal
glomerulonephritis are hematuria and edema
Depression of the total hemolytic complement
activity and C3 are seen in virtually all children during the initial phase of this nonsuppurative streptococcal complication.
15. Treatment is symptomatic and the prognosis is favorable.
Prevention
The development of a vaccine for the prevention of GABHS infection has been pursued for several decades. An
unsuccessful vaccine derived from streptococcal proteins produced cross-reactive antibodies in vaccines that resulted in
rheumatic carditis and glomerulonephritis and showed progress in vaccine development. Currently, efforts are focused on
identifying peptides within the streptococcal protein that are conserved among the strains, do not produce antibodies cross-
reactive with human heart or kidney tissue, are immunogenic and are protective. Other vaccine antigens also are under
study.