Scarlet Fever Intervention

A 6-year-old presents with his parents, with a chief complaint of a 3 day history of sore throat, intermittent frontal headache and fever with a 1 day history of a non pruritic fine, raised rash, without N, V, D or C. He is able to take fluids without difficulty but has diminished appetite. The parents report that other children in their son’s kindergarten class have been sick with similar signs and symptoms. A rapid strep screen is positive. Clinical evaluation is consistent with scarlet fever. The child has no drug allergies. 

Which of the following is the most appropriate intervention?

A. IM penicillin

B. Oralamoxicillin

C. Topical triamcinolone

D. No specific therapy is needed.

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Transcript

Voiceover: Welcome to NP certification Q&A presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Doctor Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question, so you can better understand how to arrive at the correct test answer. 

So, if you're ready, let's jump right in. 

Margaret Fitzgerald: A 6-year-old presents with his parents, with the chief complaint of a 3-day history of sore throat, intermittent frontal headache and fever with a 1-day history of a non-pruritic fine, raised rash without nausea, vomiting or diarrhea or constipation. 

He's able to take fluids without difficulty but has diminished appetite. Parents report that other children in their son's kindergarten class have been sick with similar signs and symptoms. 

A rapid strep screen is positive. Clinical evaluation is consistent with scarlet fever. 

The child has no drug allergies. Which of the following is the most appropriate intervention? 

A: IM penicillin.  

B: Oral amoxicillin. 

C: Topical triamcinolone. 

D: No specific therapy is needed. 

And the correct answer is B: Oral amoxicillin. 

Where should you start? 

Given that we're provided with the child's diagnosis and asked how to treat, this is clearly a planned intervention question. 

Scarlet fever also known as scarletina, is a communicable or contagious 

childhood disease that at one time truly struck terror in the hearts of parents and caregivers. 

Now, with readily available and highly effective antimicrobial therapy, 

complications of scarlet fever such as rheumatic fever are quite rare. 

Keeping in mind principles of epidemiology, children aged 5 to 15 

are most commonly affected. 

And here we have a child with scarlet fever who's been in contact with kids who have a similar illness. 

Having this information is so helpful and should make you think this is in fact a contagious disease. 

Another way of thinking about scarlet fever-because I'll tell you even now, if you say the word scarlet fever, parents can get very, very, very, frightened by that term because they've heard things from their parents 

or grandparents or whatever, but it's actually a strep throat infection, which is skin rash. 

So it's characterized by pharyngitis that is in the predominantly in the aforementioned age groups, usually seen in the winter and the spring. 

The causative organism of scarlet fever is Streptococcus pyogenes, a.k.a. group A beta hemolytic strep, a gram-positive bacteria, and that is the most common cause of bacterial pharyngitis, or strep throat. 

The incubation period can be from 12 hours to 7 days, and kids are contagious from the-during the acute illness and subclinical phase. 

You'll note in the history of present illness that the sore throat preceded the skin eruption. 

And that's usually what you will have is a hallmark of scarlet fever. The rash is described as sandpaper-like. And you probably you might have heard me say this in another podcast, but I swear, every time I see a kid with scarlet fever, I think to myself, that rash doesn't look like it's going to feel like sandpaper. 

And then it does. And it's usually with this rash. The kids are not that itchy, it's not like, urticaria or hives reaction where the poor child just is itchy, itchy, itchy and miserable with it. 

Now the presence of disease does not imply more severe or serious disease or higher risk of contagion. 

And in this scenario, we're given confirmation of the presence of group A beta hemolytic strep by the positive strep screen. 

No further diagnostics are needed. Treatment for scarlet fever is identical to that as you would do with strep throat. 

Oral penicillin, or amoxicillin, is the first-line therapy, while the first-generation cephalosporins can also be considered. Something like the presence of severe penicillin allergy was where cephalosporin therapy is considered to be inappropriate. 

A macrolide like azithromycin, clarithromycin, erythromycin or clindamycin can be used at the same time with the use of a macrolide 

or clindamycin. 

There is upwards to a one-third resistance rate, which miraculously group A beta hemolytic strep remains quite sensitive to a penicillin. 

Historically, the duration of treatment for strep throat has been 10 to 14 days of antimicrobial therapy. 

In reality, probably 5 to 7 days of therapy is adequate. But we don't have super, super robust back up on that. 

If you really and truly do think that adherence to 10 days of antimicrobial therapy is unlikely, then you can use a cephalosporin where there is evidence at 5 to 7 days of therapy is adequate. 

Clinical improvement is usually seen within 24 to 48 hours of the active 

therapy, and contagion is reduced in that time period. 

I do want to make one comment. The rash with strep throat often starts 

to peel in 2 or 3 days after it has erupted. 

These kids look like snakes, so it's like they're just shedding their skin, but it sheds down to good looking skin. 

You know, it's not like terribly denuded, but I always, always, always 

want to make sure I advise parents and caregivers about that because it is frightening to see the kid feel like that. 

But that information in mind, let's take another look at the question. 

A 6-year-old presents with his parents, with the chief complaint of a 3-day history of sore throat, intermittent frontal headache and fever with a 1-day history of a non-pruritic fine, raised rash without nausea, vomiting or diarrhea or constipation. 

He's able to take fluids without difficulty but has diminished appetite. Parents report that other children in their son's kindergarten class have been sick with similar signs and symptoms. 

A rapid strep screen is positive. Clinical evaluation is consistent with scarlet fever. 

The child has no drug allergies. Which of the following is the most appropriate intervention? 

A: IM penicillin. Well, here we go. This is an answer that is technically correct, but one more time is not the best answer. 

So often in the NP boards there are two correct answers, but one is the better answer. 

And remember the adage in prescribing if the gut works, use it. 

This child is taking fluids. Yes, appetite's a little funky, but he can take and keep down P0. PO penicillin is as effective as IM penicillin. 

However, P0 is preferred as the IM route subjects the child to a painful injection. 

In addition, if the child develops a significant allergic reaction to penicillin, granted a rare occurrence, the reaction is typically more severe with the use of an injectable form. 

So regardless of age, remember the adage in pharmacology is if the gut works, use it. 

And IM penicillin is super thick. It's you know, it's like, it's about as thick as maybe a hydrating cream would be. 

And it is a pretty uncomfortable, injection. B: Oral amoxicillin. 

This is the best answer. The gut works. Use it. 

You could also use P0 penicillin, but I cannot say this strongly enough. 

P0 liquid penicillin has an utterly vile taste to it. 

I know the pharmacy can always add on some flavoring, etc. it still tastes horrible. 

It's almost like it tastes moldy and plain. Amox tastes like bubble gum or strawberries, so it's kind of delicious and the kids will usually take it. The other thing is this is a 6-year-old, you know, some 6 year olds can swallow pills. 

So, you know, a lot of times, though, a 6-year-old with a sore throat is not going to swallow a capsule. 

So you're a lot of times just plain better off with the liquid. 

The liquid form of the amoxicillin. 

Option C: Topical triamcinolone. Here is a key point. You might say, yeah, but why not give the kid some triamcinolone? 

Maybe it'll clear the rash up earlier. First of all, it won't. 

And scarlet fever is not a skin condition, but rather the dermatologic manifestation of an infectious disease. 

Topical steroids can have very little impact on recovery. The rash with scarlet fever is also, as I mentioned before, usually not terribly itchy. But remember that it will peel in a few days. 

But it is startling on the rare occasion that you have a child who has an itchy rash with scarlet fever. Usually, again, not that itchy, do something like a topical antihistamines cream, like a topical Benadryl, 

or maybe something systemic for the itch. 

And D: No specific therapy is needed. Obviously this is, incorrect because anti-microbial therapy will hasten recovery, reduce contagion, and minimize the risk of complications. 

Key takeaway: practicing with best evidence is key to clinical and in NP board success. 

Voiceover: Thank you for listening to NP certification Q&A presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast and for more NP resources, visit fhea.com.