At-Home Rapid Strep Testing

Rapid strep test kits can be purchased by anybody to be done at home which may save parents/patients a lot of money in doctor visits for those prone to strep infections. Indeed, should a rapid strep test be positive, than you know that a doctor's visit is definitely worthwhile. (A doctor visit may still be worthwhile since a sore throat may be due to something else like cancer, aphthous ulcer, sinus infection, reflux, etc).

Such home kits (which in fact are the same kits used in medical offices) can be purchased online through Amazon. The price is surprisingly affordable at around the cost of a single copay $30 to do 25 tests.

However, with the purchase of such DIY kits, there are some pitfalls patients should be aware of if they decide to proceed.

1) Perform the internal controls that come with the kit!!! The kit may be a dud and needs to be tested against itself to ensure accurate results whether negative or positive. If the controls do not work, throw the whole test kit out and buy another.
2) You must follow the directions precisely, otherwise the test results will be unreliable. In other words, if the directions call for 4 drops, than it MUST be 4 drops (not 3 drops or 5). If directions state to wait 4 minutes... you must wait exactly 4 minutes. This literally is like precision baking.
3) The test strips need to be kept in protected, sealed bag and used immediately after taking one out, otherwise the test results will be unreliable.
4) When swabbing the throat, you MUST get the cotton tip on the tonsil and/or back wall of the mouth which than must be rubbed around a couple times. Getting the tongue or cheek will increase the risk of a false negative. As such, it may be worthwhile to invest in some tongue blades to help push the tongue down in order to perform this test properly.

Should patients elect to start performing home strep tests, please be aware that physicians will be obligated to not only REPEAT the testing but also examine the patient to ensure antibiotics are appropriate. An actual throat culture may be performed as well which is the gold standard test.

1) Repeat testing is required because the patient may not have followed the instructions precisely. For example, the test strips must be read at 5 minutes (variable depending on the kit). If test results are read past 5 minutes, it may incorrectly show a positive result.
2) Some patients unfortunately fabricate test results just so they can get an antibiotic without an office visit.
3) Some patients unfortunately also fabricate test results in order to skip work or school for personal reasons not related to an actual medical condition.
4) There are situations that even though the strep test is positive, no treatment may be recommended. The patient may be a strep carrier for which treatment of any kind is not recommended.

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What is the Best Antibiotic for Strep Throat?

The traditional answer for the best antibiotic to treat strep throat is penicillin. This antibiotic works astoundingly well... until it doesn't. Why is that?

Although in the lab, penicillin is probably the most effective antibiotic against Group A beta-hemolytic streptococci (GABHS) or "strep throat" infection, when it comes to human beings, it doesn't always work. A recent paper out of Georgetown elucidates the reasons why that might be the case and also explains why if you took a survey of ENT doctors, clindamycin and augmentin are perhaps the two most popular antibiotics used in our patient population (patients seen in an ENT practice suffering from recurrent and/or severe infections of the head and neck region).

Penicillin may fail to work because:

• presence of beta-lactamase producing bacteria that "protect" strep from penicillins
• absence of bacteria that interfere with the growth of strep
• co-aggregation between strep and Moraxella catarrhalis
• poor penetration of penicillin into the tonsillar tissue cells which allows intra-cellular strep and Staphylococcus aureus to survive

Indeed, in the treatment of recurrent and chronic strep throat, clindamycin or amoxicillin-clavulanic acid (augmentin) can eradicate both aerobic and anaerobic beta-lactamase producing bacteria as well as strep itself. Cephalosporins and clindamycin have superior intracellular penetration which enhances their efficacy as well.

Of course, if a patient has suffered from such severe and recurrent strep infections, it just might be time to remove and tonsils and adenoids surgically.

Reference:
Penicillin failure in the treatment of group A streptococcal pharyngo-tonsillitis: Causes and solutions. Journal of Pediatric Infectious Diseases. Volume 8, Number 2 / 2013 Pages 59-69

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PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus)

Only in kids, there is a VERY rare (and controversial) disorder where strep throat infections can rapidly lead to involuntary tics including chronic throat clearing, cough, head/neck movements, sneeze, etc as well as OCD behavior. Known as PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus), it is felt to be an autoimmune reaction triggered by antibodies produced by the body when fighting a strep infection. With this disorder, an evaluation with a pediatric neurologist is warranted.

However, what role if any an ENT may play is less certain. Obviously, the main ENT related concern is whether tonsillectomy and adenoidectomy is helpful.

Certainly, this surgery should be pursued if the child meets the guidelines of when T&A should be performed from an infectious standpoint in any child:

• 7 or more tonsil/strep infections within past 12 months OR
• 5 infections in each of the last 2 years OR
• 3 infections in each of the last 3 years

However, it has been demonstrated that T&A does NOT seem to affect the onset nor influence the neuropsychiatric course of a child suffering from PANDAS.

According to one research, no significant differences were found between children who had T&A and those who did not in terms of PANDAS classification, and OCD or tic severity. In fact, most children with PANDAS had surgery before onset of neuropsychiatric symptoms and surgery did not affect symptomology.

More info about PANDAS can be found here.

To find a doctor who is familiar with PANDAS, click here.

References:
Tonsillectomies and Adenoidectomies Do Not Prevent the Onset of Pediatric Autoimmune Neuropsychiatric Disorder Associated with Group A Streptococcus. Pediatr Infect Dis J. 2013 Mar 20. [Epub ahead of print]

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What is the BEST Way to Disinfect a Toothbrush?

In my previous blog article, I discussed the debate over whether a toothbrush becomes "contaminated" leading to the practice of throwing them out after a strep throat infection. Although the answer is still ambiguous whether it helps or not, the fact that even NEW toothbrushes contain harmful bacteria brings even more confusion on what to do.

Going on the assumption that bacteria on a toothbrush is harmful and if a new or old toothbrush contain such bacteria, perhaps the best practice would be to disinfect toothbrushes on a regular basis.

Would toothbrush disinfection work best by...

• Microwave
• Ultraviolet light (examples in this list from Amazon)
• Dishwasher
• Listerine
• Crest Pro-Health
• Air dry
• 3% Hydrogen Peroxide

Although the ultraviolet sanitization method is perhaps getting the most attention due to the high-tech nature, researchers have found that though this method did significantly decrease bacteria load, they also have found this method to be the least effective compared to other measures.

Rather, the best way to disinfect a toothbrush is by rinsing the toothbrush with Crest Pro-Health mouthwash for 20 minutes OR having it go through a normal dishwasher cleaning cycle.  3% Hydrogen Peroxide was also found helpful.

Interestingly, Listerine didn't work much better than air-dry alone and ultraviolet light didn't do much better.

Bottom line?

Don't waste your money on ultraviolet light toothbrush treatments.

Rather, if you already use a dishwasher regularly, stick the toothbrush in there. If you already like gargling with mouthwash, get Crest Pro-Health which can also disinfect toothbrushes effectively.


References:
Disinfection of toothbrushes contaminated with Streptococcus mutans. Am J Dent. 2011 Jun;24(3):155-8.

Germicidal activity of antimicrobials and VIOlight Personal Travel Toothbrush sanitizer: an in vitro study. J Dent. 2010 Aug;38(8):621-5. doi: 10.1016/j.jdent.2009.08.011. Epub 2009 Sep 23.

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Should Toothbrushes be Thrown Out After Strep Throat?

As with so many things with medicine, this question which sounds so straightforward unfortunately has no straightforward answer.

After all, there have only been a few studies that have specifically looked to answer this question.

And the answer is decidedly ambiguous as the few studies done so far either support or disprove this practice.

Two studies have found no difference in recurrent infections whether one keeps using an old toothbrush or replaces it with a new one after a strep throat. In one study, even NEW toothbrushes contained harmful bacteria.

Of course, there are several studies that support this practice.

In fact, environmental hygiene in general is also disputed with studies supporting for as well as against this practice after an illness.

Check out a few references below to add more mud to the confusion.

Of course, with multiple recurrent episodes of strep throat, tonsillectomy surgery is quite helpful.

Also given the confusion, perhaps the safe course would be to disinfect a toothbrush regularly.


References Against Throwing Toothbrushes Out:
Recurrence rate of streptococcal pharyngitis related to hygienic measures. Scand J Prim Health Care. 1998 Mar;16(1):8-12.

How dirty is your toothbrush? Answer: Not as much as you think. NBC News 5/4/13


References in Support:
Contamination of toothpaste and toothbrush by Streptococcus mutans. Scand J Dent Res. 1978 Sep;86(5):412-4.

Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis. Arch Otolaryngol Head Neck Surg. 1998 Sep;124(9):993-5.

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How Many Infections in a Child is "Normal" Per Year?

Kids get a lot of infections... but at what point should a parent be concerned on how often these infections occur, particularly upper respiratory infections?

A German study went about to determine the answer to just that question... They prospectively followed 760 children born in 1990 and followed them for 12 years. Parents recorded the child’s illnesses in a diary and answered structured questions yearly up to age 12.

This is what they found... The mean number of infections per year for each age group (standard deviation):

• 0-2 years: 3.4 episodes (3.7) per year
• 3-5 years: 2.3 episodes (2.6) per year
• 6-12 years: 1.1 episodes (1.2) per year

Two standard deviations above the mean can be still considered within normal limits, though on the high side of normal:

• 0-2 years: 11 episodes per year

• 3-5 years: 8 episodes per year

• 6-12 years: 4 episodes per year

If a child gets more than this number of infections per year, one may need to consider possible immunodeficiency.

Source:

History of respiratory infections in the first 12 yr among children from a birth cohort. Pediatric Allergy and Immunology. Volume 19, Issue 6, pages 505–512, September 2008.

How many respiratory infections in children are "normal" per year? Allergy Notes by Dr. Ves.

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