What is the recommended treatment for a patient with strep throat and a high rising epiglottis without fever or stridor?

Treatment of Strep Throat with High Rising Epiglottis Without Fever or Stridor

For a patient with strep throat and a high rising epiglottis without fever or stridor, a full 10-day course of penicillin V remains the recommended first-line treatment to eliminate the organism and prevent complications such as acute rheumatic fever. 1

Diagnostic Considerations

Before initiating treatment, confirm the streptococcal infection:

• Use Centor Criteria to assess likelihood of Group A Streptococcus (GAS)
• Consider Rapid Antigen Detection Tests (RADTs) for patients with high likelihood of streptococcal infection (3-4 Centor criteria)
• The absence of fever and stridor is reassuring, but the high rising epiglottis requires monitoring

First-Line Treatment

For confirmed strep throat with high rising epiglottis:

• 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 10-day duration is critical as the FDA label specifically states: "In streptococcal infections, therapy must be sufficient to eliminate the organism (ten-day minimum); otherwise the sequelae of streptococcal disease may occur." 2

Alternative Treatment Options

For penicillin-allergic patients:

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

Monitoring and Follow-up

Despite the absence of fever and stridor, the high rising epiglottis warrants:

• Close monitoring for development of respiratory symptoms
• Follow-up within 24-48 hours to assess response to therapy
• Consider cultures following completion of treatment to confirm eradication of streptococci 1

Important Considerations

• Full course completion: Emphasize to the patient the importance of completing the entire antibiotic course, even if symptoms improve quickly 2
• Hydration: Maintaining adequate fluid intake is crucial for recovery 1
• Symptomatic relief: Analgesics such as ibuprofen (400mg every 6-8 hours for adults) or paracetamol (500-1000mg every 4-6 hours) can be used alongside antibiotics 1

Common Pitfalls to Avoid

1. Inadequate treatment duration: Failure to complete the full 10-day course of penicillin can lead to treatment failure and complications
2. Ignoring the epiglottis finding: Despite absence of fever and stridor, the high rising epiglottis requires monitoring for potential airway compromise
3. Poor compliance: Studies have shown that penicillin treatment failure rates have increased to approximately 30%, primarily due to lack of compliance with the 10-day regimen 3

While some recent research suggests shorter antibiotic courses (5-7 days) may be effective 4, the current guidelines still strongly recommend a full 10-day course of penicillin for streptococcal pharyngitis to ensure complete eradication of the organism and prevent complications 1, 2.