I have an eight-year-old who gets strep throat at least four times a year. He does take erythromycin, but the strep keeps coming back. Is this normal?
Strep infection of the throat would seem to be one of the more straight forward infections to diagnose and treat, but it’s not.
Strep can be isolated by culture of the nose or throat in about 20 percent of normal people who do not have sore throats. Even in people who have definite tonsillitis and a positive throat culture, only about half show an antibody response in their blood to the strep. In other words, in the other half, some other germ — probably a virus — is causing the illness, and the strep is just hanging out without actually causing the disease.
For this reason, it is impossible to really say what the incubation period of strep might be. From my clinical experience, I would say that parents often come down with sore throats two to four days after their kids are diagnosed as having strep throat. But there’s no way of knowing if strep is really the culprit in either the child or the parent. Perhaps the parent is a chronic carrier of strep and caught a cold from the child.
So what is a conscientious doctor to do in this situation? It has been well proven that even experienced doctors cannot identify a strep throat by examination alone. Some symptoms of viral colds — like sneezing, runny nose, laryngitis, and cough — make strep less likely. But strep infection can often follow the viral cold if the person was a strep carrier. Strep tonsillitis is often worse on one side of the throat than the other, usually causes more fever than a viral cold, and is more likely to produce large tender glands in the neck. But none of these symptoms or signs is totally reliable. So we do a culture or one of the new rapid strep tests, keeping in mind that even if they are positive, the strep may not be causing the illness.
This uncertainty leads to the vast overtreatment of people with antibiotics. (Unnecessary use of antibiotics is causing real problems when germs capable of causing serious disease become resistant to them.) It is for this reason that most doctors will treat with simple penicillin, or erythromycin, rather than using one of the newer, more expensive “miracle” antibiotics.
There are, of course, some serious complications of strep infection, particularly rheumatic fever and glomerulonephritis, a reaction in the kidney to the strep. Therefore, whenever we get a positive culture or strep test, we prescribe antibiotics, even though we may be overtreating.
Your son may be getting infected from a carrier parent or carriers at school. I assume a culture or strep test has been done to verify that strep was really present all of these times and that the full course of antibiotic was taken each time. Taking less than the ten-day course of antibiotic may not be sufficient to kill all the strep. Unless he is allergic to penicillin, I would treat the next attack with that drug. Consider an injection of long-acting penicillin. That avoids the need to monitor his pill-taking for ten days. Erythromycin often upsets the stomach, and it’s hard to get people to finish the full course. It might be worthwhile for your whole family to get cultures — from the back of the nose as well as the throat — and then receive treatment if positive.
I would not suspect that four infections a year means anything bad about your son’s immune system — just bad luck that he keeps coming in contact with strep from some source.
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