1. Treatment in Practice

2. What this session includes
Diagnosing and managing sore throats
The use of throat swabs
Update on antibiotics for Strep A
What to do with recurrences
Tips on taking on taking antibiotics
Storage of antibiotics

3. Diagnosing and managing Strep A sore throats
Difficult to always differentiate clinically between strep A and viral sore throats
A throat swab is the gold standard for identifying the presence of strep A in the throat
however cannot differentiate whether there is infection or carriage

4. When do you take a throat swab
All symptomatic children in school sore throat management clinics should have a throat swab taken and results received before commencement of antibiotics
In rapid response clinics – may consider giving antibiotics to high risk individuals without a throat swab
If throat swab taken, good practice to let client know results of swab; consider discontinuing antibiotics if throat swab GAS negative
The Heart Foundation does not routinely recommend re-swabbing patients after an antibiotic course is completed

5. Treating Group A streptococcal sore throats (based on 2014 Heart Foundation guidelines)
First line treatment
Amoxicillin orally for 10 days
< 30 kg: 750 mg daily
≥ 30 kg: 1000 mg
Benzathine penicillin G, intramuscular injection, single dose
< 30 kg: 450 mg (600,000 Units
≥ 30 kg: 900 mg (1,200,000 Units)
Definite or possible anaphylaxis to penicillin or amoxicillin
Erythromycin ethyl succinate orally for 10 days
40 mg/kg/day in 2 – 3 doses
Note:
Decrease in maximum dose of amoxicillin from 1500mg to 1000mg
Maximum dose for erythromycin ethyl succinate – 3200 mg (Medsafe datasheet) to 4000 mg (New Zealand Paediatric Formulary)
Penicillin V not included as a first line treatment due to issues with adherence – has to be taken on an empty stomach, does not taste good. In order to improve antibiotic adherence we recommend once daily amoxicillin or im penicillin. Oral penicillin can be considered if you suspect glandular fever as amoxicillin can cause a rash in these people. Symptoms of glandular fever include: fever, sore throat, swollen glands, headache. More common in older adolescents and young adults.

6. Managing children who keep presenting with a GAS positive sore throat - a challenge for all
Concern expressed repeatedly at meetings, DHB visits, question times
Typically child or young person who presents with recurrent sore throats and throat swab is positive each time
Sometimes post treatment swab is positive
Causing concerns to parents
Undermining the relationship between the professional and the parent/patient

7. Confirming a Strep A carrier
Suspect if closely spaced symptomatic recurrences of pharyngitis with a positive throat swab i.e. child with repeated sore throats who always has a positive swab
Confirm by testing to check after an effective course of antibiotic has been delivered
Verbal assurance of adherence?
Directly Observed Therapy?
IM injection?
If positive swab after a known effective course of antibiotics – they are a Strep carrier

8. What does being a Strep carrier mean?
Not alone. Around 1 in 8 school age children in NZ are strep A carriers
Very little or no risk for Rheumatic Fever
Can transmit the strep A to others who may become infected and therefore at risk of RF
Especially if also have a cough
But much less likely to that those have an actually infection
Don’t swab asymptomatic children (GAS positives most likely carriage)

9. What do you do when you find a Strep carrier
Explain to the child and/or caregiver what being a carrier means
To help them avoid passing the bug onto household contacts
Emphasise the importance of sneeze and cough etiquette
Highlight the importance of not crowding children- especially when they sleep
Refer to your GP or nurse practitioner to decide whether and how to treat

10. Deciding whether to treat a carrier
Unwise to treat a known carrier if obvious viral symptoms - cough and runny nose
Don’t keep giving courses of oral amoxicillin to people who are GAS carriers - it won’t make any difference to the child and may contribute to antibiotic resistance
Refer to your lead GP or nurse practitioner
Ministry and NHF are producing a fact sheet and guidance to assist GPs and nurse practitioners
80% sore throats are viral.

11. Should carriage be treated?
Possible to “clear” the strep A carriage
Which reduces the confusion
But takes powerful antibiotics
Theoretically carriage may protect against infection with strep A
Clear once.
Key question is whether to do it again and what to do if not
Fact sheet will pick up these issues

12. For more information
Gregory P deMuri and Ellen R Wald. The Group A Streptococcal Carrier State Reviewed: Still an Enigma. Journal of Paediatric Infectious Diseases Society April 2014

13. Most school-aged children are able to learn to swallow tablets and capsules
Children are able to learn to swallow tablets or capsules from around six years
Most master the technique on their own by age ten years
Some children, particularly those with chronic conditions requiring daily medicines, can be taught to swallow pills at a younger age

14. Possible Barriers Anxiety Strong gag reflex Texture, size and shape
Children who fear swallowing pills are likely to be tense when attempting to do so which can make the process more difficult.
This tension, especially the throat, neck and chest can make the child feel like they are having trouble breathing make them feel anxious.
Learning strategies to swallow tablets and capsules effectively can help reduce the child’s anxiety
Often the parents who are also reluctant or unable to swallow medicines themselves. So it is important parents lead by example and demonstrate that swallowing pills or capsules is easy.
Fussy eaters or those who gag frequently on food and drink can often struggle with swallowing medicines.
Getting the child to take a deep breath before inserting a tablet or capsule in their mouth can help them to suppress their gag reflex.
The size and shape of the tablet or capsule, and the nature of the coating can affect the ease of swallowing.

15. Techniques for swallowing tablets and capsules
Ask the child to have a drink of water or their favourite drink to moisten their mouth
Place the tablet or capsule into the centre of the child’s mouth
Ask the child to take a big sip of their drink, and then swallow
There are many techniques for swallowing tablets and capsules, and it is appropriate for children to find the one that works for them.
In general, it is best not to throw a tablet or capsule towards the back of the mouth. This is because it can actually make swallowing more difficult.
A recommended technique for swallowing a pill or capsule is to:
Ask the child to have a drink of water or their favourite drink to moisten their mouth
Place the tablet or capsule into the centre of the child’s mouth
Ask the child to take a big sip of their drink, and then swallow

16. Top tips Yoghurts and thick drinks A straw
A small spoonful of apple sauce or ice cream
Yoghurts and thick drinks, such as milkshakes, can help ease tablets or capsules down. They may help to reduce a child’s awareness of a tablet or capsule being swallowed.
Using a straw to drink, with a tablet or capsule already in the mouth, may also help by getting the child to concentrate on the suction of the straw rather than thinking about the tablet or capsule going down.
Another technique is to put the tablet or capsule into a small spoonful of apple sauce or ice cream. This can help them slip down the throat more easily

17. Capsules Leaning forward when swallowing can help the capsule go down
Ask the child look down at the floor instead of up at the ceiling
Slip the capsule into the centre of the child’s mouth.
Ask the child to take a big sip of their favourite drink or water while still looking at the floor.
The capsule should float to the back of the child’s mouth and roll down their throat with the drink
Leaning forward when swallowing can help the capsule go down.
This technique may not be comfortable for everyone but some children may wish to try this.
- Ask the child look down at the floor instead of up at the ceiling
- Slip the capsule into the centre of the child’s mouth.
- Ask the child to take a big sip of their drink while still looking at the floor.
The capsule should float to the back of the child’s mouth and roll down their throat with the drink

18. Practice Makes Perfect
Encouraging children to swallow tablets and capsules:
Giving medicines to children:
Teaching children to swallow medicines is all about practice.
Using lollies that are easy to swallow can be an effective way of practising taking tablets or capsules.
Children begin practising with small lollies and progressively increase to larger sized lollies, which are comparable in size to tablets or capsules.