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Peds ID Abx QOTW #3 Answer

The correct answers are:

a) Do nothing and treat symptomatically

b) Perform rapid Influenza, if positive treat with Tamiflu

c) This is possibly strep pharyngitis, do a rapid Strep test and treat if positive

d) Centor Criteria suggest high probability, no need to test, treat for strep

e) Send Serology for EBV

f) Send a Monospot

Here’s how other respondents answered:

Q3 graph

ID Attending Discussion:

Deciding when to treat for Group A Strep

  • Clinician Prediction

– PPV 29%

– NPV 78%

  • Centor Criteria Centor

– Area under the ROC = 70% (fair)

– Leads to over treatment

  • If anyone has symptoms, including exudative tonsillitis alone, a test should be done to determine who needs treatment

Recommended Testing

  • School aged children with suspicion for GAS should have a rapid test done

– If positive rapid strep, treat

– Backup culture should be sent for children who have a negative test

– Treatment of high risk patients with negative rapid test while pending culture can be considered

  • Who is at highest risk = higher Centor Criteria
  • Consider alternative diagnosis

– EBV in teenager with exudative tonsillitis

  • Rash with PCN for treatment of GAS + exudative tonsillitis, consider testing for EBV as well

Treatment recommendations for GAS

  • Adults and adolescents

– PCN VK 500mg PO BID x 10 days (narrowest spectrum)

– Cephalexin 500mg PO BID x 10 days (PCN allergy with Rash)

– Azithromycin 500mg qday x 5 days (Severe PCN allergy)

  • Children

– Amoxicillin 50mg/kg (max 1gm) po qday x 10 days

– Cephalexin 20mg/kg (max 500mg) po BID x 10days (PCN allergy with Rash)

– Azithromycin 12mg/kg (max 500mg) x 5 days (Severe PCN allergy)

EBV Testing

EBV testing

  • At Harbor-UCLA, EBV serology is much faster than a Monospot (other institutions may vary)

– EBV serology Panel

  • EBV VCA IgM Ab
  • EBV VCA IgG Ab
  • EBV EBNA Ab

– Monospot in most hospitals is faster

  • Test for heterophile antibodies (not EBV specific)
  • Higher PPV in adolescents, low PPV in younger children

– EBV PCR should not be done

  • Large % of patients will have low grade viremia without disease