Treatment_in_Practice_-_recurrent_positives

Report
Treatment in Practice
PREPARED BY
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
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
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
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)
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
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
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)
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 childrenespecially when they sleep
• Refer to your GP or nurse practitioner to decide
whether and how to treat
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
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
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
Most school-aged children
are able to learn to
swallow tablets and
capsules
Possible Barriers
•
Anxiety
•
Strong gag reflex
•
Texture, size and shape
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
Top tips
•
Yoghurts and thick drinks
•
A straw
•
A small spoonful of apple sauce or ice cream
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
Practice Makes Perfect
Encouraging children to
swallow tablets and capsules:
http://www.bpac.org.nz/Supple
ment/2014/September/pillswall
owing.aspx
Giving medicines to children:
http://www.pharmac.health.nz/medi
cines/medicines-information/bestuse-of-medicines/giving-medicinesto-children#capsules

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