Strep Throat Signs, Symptoms, and Treatments
Sore throat is one of the most common illnesses around the world. This symptom accounts for an estimated 15 million doctor visits each year in the United States alone! While not all sore throats are concerning, it’s important to recognize strep throat as it can have long-term consequences affecting your heart and kidneys.
What Is Strep Throat?
Strep throat is a bacterial infection that leads to a red, sore, and scratchy throat. The name ‘strep’ throat comes from the type of bacteria known to cause the infection, Group A Streptococcus (GAS). GAS is also commonly known by its other name, Streptococcus pyogenes. Sore throats caused by anything other than GAS are not considered strep throat.
When a sore throat is caused by bacteria, GAS is the most common cause. However, only about three in ten kids between the ages of 5 and 15 years old with a sore throat have strep throat. Strep throat is even less common in adults, accounting for only up to 15% of sore throats. More commonly, sore throat is due to a virus and therefore is not strep throat.
School-age children are the most common group affected by GAS. However, kids under 5 can get strep throat through contact with older siblings or at daycare. Cases of strep throat tend to peak during the late fall and early spring, when the weather is moderate.
How Is Strep Throat Spread?
Strep bacteria are very contagious. They are commonly spread through direct contact or sharing food or drinks with others who are infected. Coughing or sneezing can spread GAS contained within tiny water droplets through the air. GAS can also live on doorknobs or other common area surfaces, which can be transferred to your mouth or nose by your hand. Tight quarters that promote close contact, such as daycares and dorm rooms, are particularly favorable for the spread of strep. After exposure to the bacteria, it usually takes between 2 to 5 days to develop strep throat.
Strep Throat Signs and Symptoms
Children older than 3 years typically develop symptoms of strep throat abruptly. In addition to a sore throat, common signs and symptoms of strep throat include:
- Upset Stomach
Kids may lose their appetite, usually due to the pain associated with swallowing. This discomfort is due to the tonsils and uvula in the back of the throat becoming inflamed and enlarged. You may also have white or yellow patches on your tonsils or in the back of your throat. Other signs include tender, swollen glands along the sides of your neck and small red or purple dots covering the roof of your mouth, known as petechiae.
Strep throat can also be associated with a distinct scarlatiniform rash. This rash consists of numerous very small, red, and slightly raised spots known as papules. The rash typically begins in the groin and armpits, then spreads to the torso, arms, and legs. The palms and soles of your feet are usually not affected. Skin affected by the rash usually starts to peel after several days. This unique rash can only occur if you have had strep throat previously, as it is caused by a delayed reaction by your immune system to one of the toxins produced by GAS.
Are the Signs and Symptoms Different in Toddlers and Infants?
Toddlers under the age of three most often have an atypical set of symptoms commonly referred to as “streptococcosis.” Rather than a clear-cut episode of a sore throat, toddlers can have a prolonged period of a runny nose, low-grade fever, and tender, swollen glands along the sides the neck.
Infants less than one-year-old may only have increased fussiness, low-grade fever, and a decreased appetite. As these symptoms are common to many infections in infants, the main clue is usually known contact with siblings or other children with strep throat.
When Should I See A Doctor?
You should contact a doctor if you or your child has a sore throat lasting more than 48 hours, difficulties swallowing or breathing, or accompanied by a rash, fever higher than 101º Fahrenheit or lasting more than 48 hours, or swollen, tender glands on the sides of the neck.
Strep Throat Diagnosis
How is Strep Throat Diagnosed?
Accurate and timely diagnosis of strep throat is essential so that you or your child can receive appropriate antibiotic treatment. While most cases of strep throat will get better on their own, strep throat does have the potential to cause many serious complications which will be discussed later. Moreover, prompt treatment can make you feel better faster, allow you to return to work or school quicker, and lessen the spread of GAS to your family or classmates.
Unfortunately, none of the previously discussed symptoms or signs alone can confirm whether you or your child has strep throat. Researchers have tried to develop sets of criteria which predict the likelihood of a sore throat being strep throat based on symptoms.
One of the more popular examples was the Centor criteria, which created a score based on your age, fever, white patches on the tonsils, tender neck glands, and the absence of a cough. However, having all four of these criteria still only correctly predicted the presence of GAS about half of the time in adults. The same rules were later shown in 2013 to be utterly ineffective in predicting strep throat in children between the ages of 2 and 16 years old.
Who Should Be Tested for Strep Throat?
Many medical societies including the American Heart Association, the Infectious Diseases Society of America, and American Academy of Pediatrics have weighed in on which patients with a sore throat should be tested. Using tests to confirm the presence of GAS in people with a sore throat allows us to use antibiotics only when necessary. In contrast, the use of antibiotics for typical cases of a viral sore throat can increase bacterial resistance, making future infections more difficult to treat.
Collectively, medical experts have recommended testing for GAS in a few situations:
- If you have either a sore throat with visible redness, swelling, and white patches OR a scarlatiniform rash without signs and symptoms that suggest a viral cause. Classic viral symptoms include a stuffy nose, pink eye, cough, raspy voice, mouth blisters or ulcers, and diarrhea.
- If you have a sore throat, fever, headache, upset stomach, and tender glands in your neck after contact with someone with a known case of strep throat or you live in a community with a recent strep outbreak. This also applies to toddlers with a persistent runny nose, tender neck glands, and low-grade fever.
- If you are suspected to have known complications of strep infections including rheumatic fever or worsening kidney function.
If you don’t fall directly into one of these groups, that does not mean your doctor will not request additional testing. There is a great deal of overlap in the symptoms of diverse types of sore throat, so ultimately the choice is at your doctor’s discretion.
What Tests Help Diagnose Strep Throat?
Tests that detect the presence of GAS bracteria in the throat can help diagnose individuals with symptoms of strep throat. Two types of tests are available, a throat culture or rapid strep test (RST). Throat culture consists of taking a sample from your throat to see if it grows GAS bacteria. Cultures can take up to 48 hours to begin growing GAS, so a diagnosis cannot be made for at least two days. RST can produce a result within minutes, as it simply detects a substance specific to GAS known as an antigen.
As you may expect, RST is typically preferred as the initial diagnostic test due to its practicality and convenience. This test is readily available at most doctors’ offices and provides very quick results, allowing for timely prescription of antibiotics if needed. RST is highly specific for GAS, so if you have a positive test you can be fairly certain that GAS is present in your throat.
In contrast, a negative RST does not 100% confirm you do not have strep throat. In fact, RST has been shown to miss up to 30% of strep throat cases. For this reason, many symptomatic children and teens will still need to have a throat culture if it is negative. This isn’t particularly cost-effective when you also consider that most kids with a sore throat will have a negative RST just because it is not strep. On the other hand, adults do not require a throat culture if their RST is negative, as they are much less likely to develop specific complications.
There is one additional major caveat to using either throat culture or RST. Research has shown us that up to 21% of children between the ages of 3 and 15 years old are GAS ‘carriers’. This means that a strain of GAS naturally lives in their throat, not causing any symptoms. Unfortunately, it also means that neither throat culture or RST can distinguish this GAS from GAS causing strep throat.
How Are RST and Throat Culture Performed?
Careful collection and transport of samples for RST or Culture are essential for maximizing detection of Group A Strep.
These are a few important things you should know about sample collection:
- Samples for both RST and Culture are obtained by robustly swabbing both the tonsils and back of your throat. The swab is usually moved in and out of the mouth, avoiding contact with the inner cheeks and tongue.
- The ability of both tests to detect GAS depends on collecting enough bacteria in the sample. You may experience some moderate rubbing pressure, and the swab may cause you to gag.
- Both RST and Culture can be negative after only one dose of antibiotic, so both should be performed before starting treatment.
- When RST is performed as the first test, it can be helpful to swab the throat twice at the same time. The first can be used for RST, while the second can be used for culture if the RST is negative.
Strep Throat Treatment
What Are the Goals of Treatment?
Antibiotics are used to treat strep throat for several important reasons:
- Reduce Symptoms: Antibiotics have been proven to make symptoms more tolerable and make them go away quicker if you have strep throat.
- Prevent Complications: While it’s true that most cases of strep throat resolve on their own in 3 to 5 days, antibiotics also play a crucial role in preventing complications that occur both shortly and long after strep throat. When left untreated, GAS can spread locally to the ears, sinuses, neck, and muscles. It can also have long-lasting effects on your immune system, causing inflammation of your heart and joints, kidney issues, and much more.
- Decrease Spread to Others: Strep throat can quickly spread to those around you, causing groups of siblings to contract the illness all around the same time. In fact, the spread of GAS to people in close contact has been shown to be up to 50%. This is mainly because when untreated, it’s possible for you to continue to spread the bacteria to others even after you begin to feel better. The bacteria can even still inhabit your throat 3 to 4 weeks after your symptoms! In contrast, it has been shown that antibiotics can completely clear the bacteria from your throat after only 24 hours in up to 91% of cases.
How Do You Treat Strep Throat?
Strep throat is treated primarily with antibiotics. Penicillin is the antibiotic of choice for strep throat due to its affordability and effectiveness. It has also been proven to decrease your risk of severe complications such as rheumatic fever.
Most adults should take 500 mg of Penicillin V by mouth 2 to 3 times a day for 10 days.
Penicillin V can also be used for most children with the dose dependent on his or her weight. Alternatively, young children can be prescribed Amoxicillin, since the liquid form of this medication tastes much better than Penicillin. Amoxicillin also allows for once a day dosing and have been shown to be equally as effective as Penicillin.
Treatment with either oral penicillin or amoxicillin should be for ten days. While your symptoms may get better after only a couple days, its possible some bacteria will remain in your throat. If not completely cleared, the bacteria will have the opportunity to repopulate your throat and cause a second infection!
Note, you or your child can also receive Penicillin as an injection. The injection has been shown to be equally as effective in treating strep throat and preventing complications. However, it is more expensive, and supply can be limited.
What If I Have Strep Throat and an Allergy to Penicillin?
Cephalosporins, macrolides, and clindamycin can all be used to treat strep throat if you are allergic to or cannot tolerate Penicillin. Choosing between these options will depend on the severity of your allergy, local trends in antibiotic resistance, and doctor preference.
Some general guidelines recommended by the American Academy of Pediatrics include:
- If your allergy is mild, such as a rash after starting to take Penicillin, you may take a 1st-generation cephalosporin such as Keflex (cephalexin).
- If your allergy is moderate, such as hives or swelling, you may use a 2nd or 3rd generation cephalosporin such as Ceftin (Cefuroxime), Cefdinir (Omnicef), or Cefpodoxime (Vantin).
- Most oral cephalosporins should be taken for 10 days similar to Penicillin. However, both Cefdinir and Cefpodoxime can be given for only 5 days, as they have been shown to be as effective in this shorter time frame.
- If your allergy is severe, with difficulty breathing or swelling of the face, throat, tongue or large areas of your body, you should not take cephalosporins. A macrolide, such as Azithromycin (Zithromax) can be used instead. Azithromycin stays in the body for an extended period of time, so can be given over the course of only 3 to 5 days.
- There have been reported cases of strep throat resistant to Azithromycin. In these cases, a ten-day course of Clindamycin (Cleocin) can be an acceptable alternative. Clindamycin may also be used in children with multiple episodes of strep throat over a short period of time.
Can I Use Anything Else to Relieve My Strep Throat Symptoms?
You can also implement supportive measures such as getting some rest and drinking plenty of fluids. Tylenol or Ibuprofen can be used to alleviate fever and discomfort.
Other soothing methods include sipping warm tea with honey or lemon, eating frozen desserts such as popsicles or ice cream, sucking on hard candy or ice, and gargling warm salt water. Of course, not all of these methods are appropriate for young children and should be used with caution.
When Can My Child Return to School After Having Strep Throat?
In most children, fever and sore throat will begin to resolve within one to three days after starting antibiotics. As long as your child does not still have a fever, they may typically return to school after one full day of treatment.
Does My Child Need to Return to the Doctor to Confirm the Infection is Gone?
Most children do not need to be rechecked by a doctor after completing their course of antibiotics. You should consider returning to your doctor if your child’s sore throat or symptoms get worse or continue for more than 3 days following the start of treatment.
My Child Keeps Getting Strep Throat, Does He or She Need to Have Their Tonsils Removed?
It is rare that surgical removal of your child’s tonsils is required for multiple episodes of strep throat. However, this can only be determined by you and your doctor based on your child’s medical history and other factors.
Strep Throat Complications
What Are Potential Complications of Strep Throat?
Complications after strep throat come in two forms, known as suppurative and non-suppurative.
Suppurative complications are caused by the spread of infection to other areas of the body, usually those closely connected to the throat or nose. Examples include spread of the infection to the ears, sinuses, spinal cord, blood, skin, and muscles. Antibiotics have been shown to significantly decrease the risk of developing these types of secondary infections in the period following strep throat.
Non-suppurative complications are not as straightforward and can occur long after strep throat if untreated. These complications can affect many major vital organs and even be life-threatening. Hence, they are a dominant driving force in accurately identifying and treating strep throat, particularly in children.
Examples of non-suppurative complications of strep throat include:
- Acute Rheumatic Fever (ARF): ARF is a delayed, exaggerated reaction to a part of the bacteria by your immune system. It typically occurs 2 to 3 weeks after your sore throat. The symptoms can vary, however, ARF can cause arthritis, nodules in the skin, rash, involuntary muscle movements, and even inflammation of the heart.
- Post-Streptococcal Reactive Arthritis: This arthritis occurs about one month after your sore throat. It causes redness, swelling, and pain in one or more of your joints, such as the knees or elbows.
- Streptococcal Toxic Shock Syndrome (Strep TSS): This is a rare and severe spread of GAS to the bloodstream where it can affect your major organs. Strep TSS causes high fever, increased heart rate, chills, muscle aches, nausea, vomiting, and diarrhea.
- Post-Streptococcal Glomerulonephritis: Some strains of GAS can affect the kidneys to a varying degree. This condition is most common in children under seven years old. Your child may have red or brown urine, cloudy urine due to high protein levels, lower body swelling, nausea, or vomiting.
- PANDAS syndrome: PANDAS stands for Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Strep. This condition can cause your child to develop an obsessive-compulsive disorder or muscle tics following strep throat.
If you believe your child is experiencing any of these complications, you should contact a doctor immediately.
Read more in our Strep Throat series: