What is the treatment for strep throat with a high rising epiglottis?

Treatment of Strep Throat with High Rising Epiglottis

For strep throat with a high rising epiglottis, the primary treatment is a full 10-day course of penicillin V (250 mg three times daily for adults or appropriate weight-based dosing for children), with close monitoring for potential airway compromise. 1

Initial Assessment and Diagnosis

• Use Centor Criteria to assess likelihood of Group A Streptococcus (GAS) pharyngitis
• Confirm diagnosis with Rapid Antigen Detection Test (RADT) in patients with high likelihood (3-4 Centor criteria)
• The presence of high rising epiglottis requires careful airway assessment and monitoring

Antibiotic Treatment Algorithm

First-line Treatment:

• Penicillin V:
  • Adults: 250 mg three times daily for 10 days
  • Children: 600,000 U for <27 kg and 1,200,000 U for ≥27 kg for 10 days 1
  • The full 10-day course is essential to prevent acute rheumatic fever and achieve maximal pharyngeal eradication 1, 2

For Penicillin-Allergic Patients:

• Clindamycin: 300-450 mg orally three times daily for 10 days 1
• Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 1

Important: The oral route should not be relied upon in patients with severe illness, nausea, vomiting, gastric dilatation, cardiospasm, or intestinal hypermotility 2

Special Considerations for High Rising Epiglottis

1. Airway Management: Close monitoring for signs of airway compromise
2. Hospitalization: Consider for patients with significant epiglottic inflammation
3. Hydration: Ensure adequate fluid intake
4. Symptom Relief:
   • Ibuprofen: 400mg every 6-8 hours (adults) or 5-10mg/kg every 6-8 hours (children)
   • Paracetamol: 500-1000mg every 4-6 hours (adults) or 10-15mg/kg every 4-6 hours (children) 1
   • Avoid aspirin in children due to risk of Reye syndrome 1

Follow-Up and Monitoring

• No routine post-treatment throat cultures are recommended after completion of therapy 1
• Reassess patients whose signs and symptoms return after completing therapy 1
• Monitor for potential complications:
  • Airway obstruction
  • Abscess formation
  • Treatment failure

Common Pitfalls and Caveats

• Inadequate treatment duration: A full 10-day course of antibiotics is necessary to prevent acute rheumatic fever and achieve maximal pharyngeal eradication 1, 2
• Poor compliance: The bacteriologic failure rate with penicillin has increased over time, potentially due to lack of compliance with the 10-day regimen 3
• Missed airway assessment: Failure to monitor for progressive airway compromise in cases with epiglottic involvement
• Inappropriate oral administration: Oral antibiotics may not be adequately absorbed in patients with severe illness 2
• Delayed treatment: Early treatment can reduce symptom duration to less than 24 hours in most cases and decrease the incidence of suppurative complications 4

While some studies suggest cephalosporins may have better clinical outcomes than penicillin 5, and clarithromycin may have higher bacteriologic cure rates 6, the Infectious Diseases Society of America guidelines still recommend penicillin as first-line therapy due to its proven efficacy, safety profile, and narrow spectrum 1.