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Posts posted by Mayzoo

  1. My DD is 10 now and we have always home schooled. Our worst was from Sept 12, 2011 to March 15, 2012. and then started again for about 2 months in May 2012 and we just came out again from another 2 months a few weeks ago.


    It is exhausting, but we have other issues we deal with as well. I try to keep in mind that kiddo is no less tired of this than I, and she suffers more than I during these episodes. It helps me keep things in perspective a little when I am suffering from sleep deprivation and not having enough space to even walk because she is my shadow at all times.


    Deep breaths and know you are not alone :).

  2. Here is an article about Prophylaxis, but the abx they used were zith and/or penicillin. Still it is about prophylaxis so I hope it helps (sorry I did not have time to read them):


    NIMH article


    Here is another article in full since you may have to be a member at medscape to see it:


    PANDAS in Children -- Current Approaches


    Richard P Barthel, MD


    Faculty and Disclosures


    CME/CE Released: 12/11/2002; Valid for credit through 12/11/2003

    CME/CE Information



    Postinfectious autoimmune disorders in response to Streptococcus infections were confirmed in the 1950s.[1] Rheumatic fever (RF) was the prototype disorder and Sydenham chorea (SC) was identified, not only as a criteria for the diagnosis of RF but also as a stand-alone manifestation of the potential for a central nervous system autoimmune response. SC can have a mix of both motor and psychiatric manifestations, including hyperactivity, mood lability and, in severe cases, psychosis. Behavioral symptoms often precede the motor manifestations and can include obsessive-compulsive features. On average, SC lasts about 6 months.[2]

    Defining the PANDAS Subgroup


    Swedo and colleagues[3] first proposed that some cases of childhood-onset obsessive-compulsive disorder (OCD) might be, like SC, a post-step disorder of immune character. They coined the acronym PANDAS to identify the occurrence of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. This is a disorder of prepubertal children with sudden and dramatic onset of OCD post-streptococcal infection. Dr. Susan Swedo,[4] from the Pediatric Developmental and Neuropsychiatry branch of the National Institute of Mental Health (NIMH), presented that these children have a remarkably episodic course with remitting and relapsing OCD symptom severity. Her criteria for a PANDAS presentation also require the presence of associated neurologic problems. These are usually "choreiform" movements, which, by definition, are not full-blown SC. In fact, these are often subtle movements. They do not interfere with voluntary motor control and may only be elicited with careful observation of the extended hand/fingers. Such movements were present in 25 of 26 children seen during an exacerbation of their OCD symptoms in the early studies at NIMH.[5] The exacerbations must also have a temporal relationship to repeated Group A beta-hemolytic Streptococcus (GABHS) infections.


    Dr. Swedo reported that there was an initial sense by clinicians that a larger spectrum of psychiatric disorders (eg, attention deficit/hyperactivity disorder, autism, anorexia nervosa) might also be placed under the PANDAS rubric. However, she feels strongly that this subgroup classification should be reserved, at this time, for OCD and tic disorders. The full Diagnostic and Statistical Manual of Mental Disorders, 4th edition[6] criteria for these disorders must be met before PANDAS should even be considered.


    Current thinking, according to Dr. Swedo, does allow for "possible" PANDAS to be considered if there is a child with a prepubertal onset relapsing/remitting OCD and/or tic disorder. This is true only if the neurologic problems and relationships to GABHS infections have not been fully explored or documented. She feels that knowledge of the PANDAS associations must encourage clinicians to search for the "missing" criterion with each exacerbation. Thus, the pursuit of laboratory confirmation of the GABHS infection should be undertaken.


    Dr. Harry Hill,[7] Infectious Disease specialist and Streptococcus researcher at the University of Utah School of Medicine, reported that the current "rapid" streptococcal screens used in most clinics are perfectly acceptable for proving the presence of the Streptococcus if positive. However, if the rapid screen is negative, this is not a true indication of the absence of infection. A full plate culture needs to be done. Retrospective assessment of exposure to Streptococcus will require the use of immune markers (eg, AntiStreptolysin O [ASO], Anti-Dnase-B). It should be recognized that the ASO titer is not elevated at the time of acute infection. It is an antibody response peaking in 2-4 weeks. An elevated level can last for 6-12 months before, barring reinfection or other complications, it returns to baseline. Criteria for true diagnostic titers require both acute and convalescent specimens. Diagnostic levels (reported in Todd units) can vary among labs and are age-dependent. Anti-Dnase-B (also known as Streptodornase) is less discriminating (20% of the healthy population have elevated levels). Since these titers rise more slowly and remain elevated longer, they may be helpful in some cases. Franciosi stated that paired titers showing a 4-fold rise should be considered positive.[8] He also noted that combined testing, using both tests along with the Antihyaluronidase titer as a Streptococcus "panel," is reported to be 90% confirmatory of a Streptococcus infection.

    Genetic Risks?


    There does appear to be a genetic susceptibility to poststreptococcal autoimmune disorders, including RF and SC. Previous research focused on the D8/17 antibody. This monoclonal antibody identifies B-cell antigens present in all patients with RF, where it has been studied extensively.[9] Dr. Tanya Murphy, of the University of Florida, noted that, unfortunately, it has been found to be rather nonspecific in neuropsychiatric disorders. In addition, she and Dr. Hill[7] both considered the reliability and validity of the assay to be suspect. The lack of usefulness of this laboratory marker for any diagnostic purpose in suspected childhood PANDAS was reinforced by Dr. William McMahon.[10] Therefore, currently, it seems to have no place in the assessment of PANDAS in children.


    Dr. McMahon, Child Psychiatrist and Geneticist at the University of Utah, studied the broader area of general familial genetic risk. He looked for the presence of OCD and tic disorders in families involved in the current RF resurgence in his region. (Dr. Hill[7] reminded clinicians that the incidence of RF was in significant decline through the mid-1980s but is now more prevalent in some areas [eg, intermountain region of the western United States] for reasons that are poorly understood.) His goal was to see if Tourette disorder (TD) or OCD was associated with the SC criteria for RF. In a pilot survey of 100 families, he found almost 4 times as many SC probands (22%) had relatives with TD/tics or OCD than non-SC RF patients (6%). He feels this supported an as yet unidentified "common genetic risk factor." This should prompt clinicians to be careful about the family history of children who are suspected of PANDAS.

    PANDAS -- Management and Treatment


    The recent report by Murphy and Pichichero[12] is the first evidence that it may be possible to identify children with potential PANDAS more acutely. This report, from a vigilant pediatric practice, identified 12 children with new-onset PANDAS-like presentation over 3 years. All had GABHS infection, sometimes mild in classical (ie, tonsillitis/pharyngitis) presentation, with abrupt appearance of OCD symptoms. (Intriguingly, in this study, there was also the new onset of daytime urinary urgency/frequency in 7 of 12 patients.) If antibiotic treatment was successful in eradicating the streptococcal infection, the OCD symptoms also resolved. Recurrence of OCD symptoms, with recurrent GABHS infection, was found in 6 of 12 children. Appropriate treatment again relieved the OCD symptoms if the infection was managed. Given the success of antibiotic treatment in the prevention of 90% of RF and 50% of acute poststreptococcal glomerulonephritis, this study supports the vigorous inquiry and treatment of GABHS infections as a potential prevention effort of PANDAS as well.[7]


    Treatment for the PANDAS subgroup of children with OCD is not different from treatment for others with this diagnosis. Dr. Murphy recommended the use of combined behavioral therapies and low doses of selective serotonin reuptake inhibitors (SSRIs) with rapid taper to clinically effective levels as reported in the literature.[9,11] Controversies arise when treatment is less than ameliorating or if the exacerbations are problematic.


    Perlmutter and colleagues[13] have published the results of their attempts at immunomodulatory therapy with more severe and treatment resistant children with PANDAS. Part of the NIMH group studying these disorders, they found that both intravenous pooled immunoglobulin (IVIG) and plasma exchange (PE) were successful in reducing OCD and other behavioral symptoms. Gains were maintained for up to 12 months. PE was reported to produce more rapid onset of change (< 2 weeks) and had "more striking" improvements in OCD.[5] Given the complications/risks of IVIG, this is not recommended currently by Dr. Swedo as a treatment. She agreed with the NIMH statement[14] that this is an experimental intervention. Dr. Swedo did report that she feels that children with more severe symptoms should be considered for therapeutic plasma exchange if other interventions have failed and there is a clinical exchange team available who has experience with young children.[4] She indicated that families need to know this is an area of ongoing research and that PE and other modalities for treatment are under continuing study at NIMH.


    An active question in that research is the effect of prophylactic antibiotics (PAbx) in children with PANDAS. This is another difficult area for clinicians. PAbx are routine for those with carditis resulting from RF, and their success in prevention of further heart damage is a clear indicator of the relationship between GABHS and RF. Early studies[15] of PAbx in children with PANDAS have been complicated by poor compliance and the dilemmas of placebo treatment. Since study children will be at risk for GABHS infections through the study period, ethically they require treatment. Dr. Swedo presented early indications of clinical directions from unpublished data[4] but felt it was "too early" to recommend this. Her strongest concern was how long to continue antibiotics if they are started. This and other unanswered questions will continue to guide the study of PANDAS.


    Finally, the question of how much of "typical" OCD may have its genesis in postinfectious etiology is a tantalizing one. Given the interest of psychiatry and child psychiatry in finding clear etiologies for many disorders, the possibilities of viral and bacterial contributions to currently poorly understood disorders and their exacerbations make the evolving PANDAS story a model for all clinicians to watch.

    Clinical Correlation


    An 8-year-old girl presents to her MD's office with sudden onset of frequent hand washing with distress about "germs"; she has a sore throat. Mother is known to have struggled with OCD and dad has a tic disorder. Mom is anxious about PANDAS!


    The patient should be screened with a "rapid" strep test: if positive, she should be treated with appropriate antibiotics; if negative, a plate culture should be done. In either case, the family should be counseled about appropriate behavioral approaches to the girl's obsessive-compulsive symptoms. If mother has a cognitive-behavioral therapist in place, a contact to that clinician is appropriate. Appropriate follow-up of culture, treatment to resolution of any infection, and tracking of OCD symptoms is indicated.


    Four weeks later, the girl is more significantly involved with obsessions and compulsions about germs. Contamination fears interfere with comfort at school and home. Cognitive-behavioral therapy principles have been initiated with some success. Mother has benefited from fluvoxamine and feels her daughter will also.


    Referral to a clinician skilled with the diagnosis and SSRI treatment of OCD in children is appropriate, and formal cognitive-behavioral therapy must be considered.


    Six weeks later, she has multiple severe obsessive-compulsive anxieties and evidence of "psychotic" beliefs. She is sleeping poorly and eating is constricted due to her fears. After diagnosis of OCD, there was initial positive response to the medication/therapy trial, but this recently deteriorated.


    The patient should be cultured again, and treated as appropriate. If positive, a search for a Streptococcus "carrier" in the family should be made. If negative, therapeutic plasma exchange might be considered. Consultation to the PANDAS group at NIMH, or other local experts, about this treatment and the potential usefulness of prophylactic antibiotics should be sought.



    Berrios X, del Campo E, Guzman B, Bisno AL. Discontinuing rheumatic fever prophylaxis in selected adolescents and young adults. A prospective study. Ann Intern Med. 1993;118:401-406.

    Murphy T, Goodman W. Genetics of childhood disorders: XXXIV. Autoimmune disorders, part 7: D8/17 reactivity as an immunological marker of susceptibility to neuropsychiatric disorders. J Am Acad Child Adolesc Psychiatry. 2002;41:98-100.

    Swedo S, Leonard HL, Garvey M, et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection: clinical descriptions of the first 50 cases. Am J Psychiatry. 1998;155:264-271.

    Swedo S. Pediatric autoimmune neuropsychiatric disorders associated with strep infections (PANDAS). Program and abstracts of the American Academy of Child and Adolescent Psychiatry 49th Annual Meeting; October 22-27, 2002; San Francisco, California. Symposium 26.

    Swedo SE. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Mol Psychiatry. 2002;7(suppl 2):S24-25.

    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fourth edition. Washington, DC: American Psychiatric Association; 1994.

    Hill H. Group A streptococcal infections and the pathogenesis of acute rheumatic fever. Program and abstracts of the American Academy of Child and Adolescent Psychiatry 49th Annual Meeting; October 22-27, 2002; San Francisco, California. Symposium 26.

    Franciosi R. Laboratory Services Directory -- Vol. 2, Children's Hospital of Wisconsin. Hudson, Oh: Lexi-Comp Inc; 1992.

    Murphy T. Tics, compulsions and strep throat. Program and abstracts of the American Academy of Child and Adolescent Psychiatry 49th Annual Meeting; October 22-27, 2002; San Francisco, California. Institute 1.

    McMahon W. Genetics of TD and RF: do they overlap? Program and abstracts of the American Academy of Child and Adolescent Psychiatry 49th Annual Meeting; October 22-27, 2002; San Francisco, California. Symposium 26.

    Riddle M, Reeve EA, Yaryura-Tobias JA, et al. Fluvoxamine for children and adolescents with obsessive-compulsive disorder; a randomized, controlled, multicenter trial. J Am Acad Child Adolesc Psychiatry. 2001;40:222-229.

    Murphy M, Pichichero M. Prospective identification and treatment of children with pediatric autoimmune neuropsychiatric disorder associated with group A streptococcal infection (PANDAS). Arch Pediatr Adolesc Med. 2002;156:356-361.

    Perlmutter S, Leitman SF, Garvey MA, et al. Therapeutic plasma exchange and intravenous immunoglobin for obsessive-compulsive disorder and tic disorders in childhood. Lancet. 1999;354:1153-1158.

    Plasma exchange and intravenous immunoglobin lack proven benefit and carry risk for children with PANDAS, Tourette's syndrome, or OCD. Available at http://www.nimh.nih.gov/events/pandaalert.cfm. Accessed November 15, 2002.

    Garvey MA, Perlmutter SJ, Allen AJ, et al. A pilot study of penicillin prophylaxis for neuropsychiatic exacerbations triggered by streptococcal infections. Biol Psychiatry. 1999;45:1564-1571.

  3. Getting Strep Pharyngitis Right


    An Expert Interview With Stanford Shulman MD


    Laurie Scudder, DNP, NP, Stanford T. Shulman, MD

    Nov 09, 2012Authors & Disclosures


    Editors' Recommendations


    Sore Throats Mostly Viral, Not Strep


    Editor's Note:

    The Infectious Diseases Society of America (IDSA) has just released a 2012 update of the Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis, its first update in 10 years.[1] Acute pharyngitis is common -- and most episodes, the guideline emphasizes, are not due to group A streptococcus (GAS). That does not, however, mean that patients with non-GAS pharyngitis are not receiving antibiotics. In fact, inappropriate treatment of acute pharyngitis with antibiotics is a major contributor to the rising incidence of antimicrobial resistance. Two articles just published in Archives of Internal Medicine document the continuing problem of overprescribing of antibiotics for viral infections.[2,3] In an invited commentary in Archives, Ralph Gonzales, MD, MSPH, Director of the Program in Implementation and Dissemination Sciences at the University of California, San Francisco, argued that the continuing high rate of antibiotic use is the result of a failure to translate evidence into practice.[4] Medscape spoke with Stanford Shulman, MD, lead author of the IDSA guideline and Professor of Pediatric Infectious Diseases at Northwestern University's Feinberg School of Medicine, about the evidence underpinning this new guideline and its usefulness in helping clinicians to translate this important guideline into practice.

    Examining the Evidence


    Medscape: Can you briefly review the process used by the guideline authors to evaluate evidence from the last 10 years when developing the updated guideline?


    Dr. Shulman: The guideline committee carried out a comprehensive review of the published literature since release of the last document in 2002. Individual members of the guideline committee searched publications related to all topics to be included within the guideline. We included careful evaluation of a Cochrane review that had been published recently related to this topic.[5] We reviewed guidelines of other organizations who make recommendations related to this topic as well to make sure that we understood the nature of other organizational guidelines.


    Medscape: Can you describe the strength of the evidence?


    Dr. Shulman: I think the evidence is reasonably strong in most situations but certainly not all.

    Diagnostic Recommendations


    Medscape: The guideline strongly emphasizes the need to confirm a diagnosis of GAS and not to rely on clinical suspicion. The authors then go on to list the signs and symptoms that suggest a viral or bacterial etiology. However, the guideline notes that scoring systems based on clinical signs and symptoms are relatively poor predictors of the presence or absence of GAS. Is there any scenario in which treatment based on clinical suspicion alone is appropriate?


    Dr. Shulman: The guideline does provide a list of symptoms that are commonly associated with GAS infections of the throat in addition to a list of separate signs and symptoms related to viral pharyngitis. Having laid out those signs and symptoms that are often present with GAS, it is still clear that those signs and symptoms are not sufficiently reliable or accurate to allow diagnosis of streptococcal pharyngitis to be made on clinical suspicion alone. There are simply too many false positives and some false negatives. With respect to the viral signs and symptoms, patients who have rhinorrhea, cough, mouth ulcers, and hoarseness are very unlikely to have bona fide streptococcal pharyngitis. So we can rely upon their presence to conclude on clinical grounds that the patient does not have a streptococcal pharyngitis and testing is not really indicated.


    Is there any scenario in which treatment could be based on clinical suspicion alone? I think that there are a few circumstances where the epidemiology would suggest this is reasonable. For example, if one child in a family has signs and symptoms suggestive of strep and the diagnosis is then confirmed in that child, and a sibling or someone else in the household in short order presents with an identical or very similar clinical illness, it would be reasonable to assume that the same pathogen is in the household and the likelihood of that second child having streptococcal pharyngitis as well would be extremely high. That would be a scenario in which clinical suspicion would enable one to make a diagnosis.


    Medscape: The guideline notes that rapid antigen detection tests (RADTs) have sufficient specificity for clinicians to make a decision to treat patients with a positive RADT. However, sensitivity is not ideal, and, therefore, negative RADTs in children, but not adults, should prompt clinicians to obtain a backup throat culture. Is this recommendation applicable to all clinical situations? What about situations where the RADT is obtained despite a clinical suspicion of a viral etiology in order to reassure an anxious parent? Can clinicians reasonably use an RADT to confirm a suspected viral etiology for pharyngitis?


    Dr. Shulman: Unfortunately, what one intuitively might think is a very simple situation -- we either have a virus or we have a strep infection and it shouldn't be so complicated -- can become very complicated. The answer to your question is: no. If the clinical clues are all pointing towards a viral etiology, relying upon a rapid test or a culture can be very misleading. This gets us into a discussion of the very complicated problem of the chronic streptococcal carrier. There are many children, and a considerable number of young adults as well, who become at various times colonized in the throat with GAS that does not cause an infection in the sense of making the patient ill. Carriage in chronic carriers persists many months -- 6 and even 12 months has been documented. If the individual who is a chronic carrier gets a cold and has a throat swab done, the throat swab will be positive. A rapid test and even a culture cannot reliably distinguish between a person who has a bona fide streptococcal pharyngitis and one who is a chronically colonized individual who now has an intercurrent viral illness. You can't distinguish those individuals. So, it's really not recommended to do any testing if the clinician really believes that all the signs and symptoms point towards a virus.

    What About Carriers?


    Medscape: The identification and management of a suspected GAS carrier is one of the thorniest issues discussed in the guideline, which concludes that these individuals need not be identified or treated as they are unlikely to be infectious or to develop GAS complications. However, as you have clearly illustrated, unidentified carriers presenting with acute viral pharyngitis do end up being treated with antibiotics even if the clinician suspects a viral etiology. Is there any evidence that clinicians should attempt to eradicate the carrier state?


    Dr. Shulman: On a routine basis, we believe the carrier state is not a serious issue that warrants attempts to eradicate it except in highly selected circumstances such as if there is a history of someone with rheumatic fever in the household and you do not want to have a carrier in the household. In general, it is not necessary. However, the scenario you posed earlier gets to the issue of how does one really establish the diagnosis of a GAS carrier? The patient who comes in with enough symptoms to raise the clinical suspicion of a possible streptococcal pharyngitis should be tested with a rapid test and/or throat culture. If positive, the patient should be treated. A common scenario is a child who, within a brief period of time, say a couple of months, after that initial episode, has repeated illnesses that have prompted throat swabs that are repeatedly positive. That raises the clinical suspicion that perhaps this is a child who really is not having bona fide streptococcal pharyngitis over and over again but may be a chronic streptococcal carrier.


    One way to try to clarify that situation is to wait until this child is asymptomatic and in a normal state of health. Then, culture the patient at that point in time. Finding GAS in the throat of the asymptomatic child at that point pretty much clinches the diagnosis of the chronic streptococcal carrier. That can make it easier to deal with future episodes of sore throat. Knowing that a child or an adult is a chronic streptococcal carrier should alter the indications to swab in the future. If a patient who is known to be a carrier has marginal symptoms -- not really highly suggestive of a streptococcal pharyngitis -- that would be a circumstance where it is probably wise not to do any kind of testing. If, however, a child who is a chronic carrier comes in with every symptom that strongly points towards a possible streptococcal pharyngitis, you want to err on the side of caution. You should do a swabbing and testing of that particular child. But I think that you want to use a different scale in terms of whose throat you want to swab and test when you know a patient is a streptococcal carrier.


    Medscape: And to clarify -- this is quite different from a recommendation to culture as a test of cure.


    Dr. Shulman: That is correct. While some could argue it is similar to a test of cure, it is in very selected patients and very selective circumstances.


    Medscape: Should a carrier be cultured subsequently to determine if the carrier state is still present?


    Dr. Shulman: There has never been a recommendation that one should do that. There might be selective situations, depending on the epidemiology; for example, a household with someone who is at particularly high risk of acquiring GAS from the carrier -- even though in general we view carriers to be not at all highly contagious. Carriers seem to be at very little risk to themselves in terms of developing complications of strep and at very low risk to their contacts. They do not seem to shed organisms efficiently, in contrast to someone who has a bona fide infection with presumably higher numbers of strep cells that are more actively replicating and more metabolically active and more easily transmitted from patient to patient.



    Treatment Recommendations


    Medscape: Can you speculate as to why antibiotic therapy for acute pharyngitis remains so common?


    Dr. Shulman: I think that is a really interesting question. If you have sit-down discussions with various pediatric practices, you find great variance in how commonly antibiotic therapy for acute pharyngitis is prescribed. Sometimes this occurs with no testing done, which we would consider to be quite inappropriate. Other times, testing is performed very frequently and patients with viral symptoms who are very likely to be carriers are indeed being treated over and over again. In some practices, the expectation has grown over time among the parents of the children in the practice that a child who is sick with a fever needs to come in to get an antibiotic. Generating that expectation among the patient/parent population then leads to real disappointment on the part of parents who bring their child in sick expecting an antibiotic and are told that one is not needed.


    In contrast, other practices have assiduously worked to change the expectations of parents. There is a lot of lay literature about the major problem of antibiotic-resistant organisms in our society and the contribution of antibiotic overuse to that problem. In some practices, highly sophisticated parents come in, and -- in contrast to other group of parents -- you have to talk these parents into allowing their child to get a course of antibiotics when that's indicated.


    What that tells me is, number one, parents obviously vary in their degree of sophistication about this issue. We can, as practitioners, try to educate them about the fact that antibiotics are great when they are needed, but they are not so great when not needed because they can induce antibiotic-resistant organisms, which are bad for the individual patient and bad for society. It may be faster to just write a prescription and send a family out the door. It takes a few extra minutes to explain why that would not be in the child's best interest. Over time, if I take those extra minutes, that will change the expectations of the parent population.


    Medscape: The 2012 guideline reiterates the recommendation made in the 2002 guideline for use of penicillin or amoxicillin as first-line therapy for GAS pharyngitis in patients not allergic to these agents, a recommendation based on strong, high-quality evidence. Do data indicate that these agents are indeed used as a first choice by clinicians? What about recommendations for penicillin-allergic individuals? What agents are most appropriate?


    Dr. Shulman: There are a few individuals in our country who have argued fairly strenuously that cephalosporins should be considered as first-line therapy for GAS pharyngitis in nonallergic patients. In areas where those folks have been quite vocal and influential, there is more cephalosporin use than in other areas. When I lecture to large groups of pediatricians and have asked for a show of hands about their first-line antibiotic choice for GAS pharyngitis, by far penicillin and especially amoxicillin have been the most commonly reported recommendations by pediatricians. In the family practice community, we don't have really up-to-date, scientifically sound surveillance on this point.


    There is a new wrinkle related to amoxicillin in this guideline that I think is quite important. There are now 5 published clinical studies that demonstrate that single-daily-dose amoxicillin is highly efficacious for treatment of streptococcal pharyngitis if given for 10 full days.[6-10] It is as effective as 3- to 4-times-a-day penicillin or 2- to 3-times-a-day cephalosporins. Having the ability to give a once-daily dose of amoxicillin makes it very convenient to administer. Amoxicillin suspension tastes pretty good, so for young children that is a benefit as well. It should be emphasized that there are absolutely no GAS strains resistant to those drugs -- not a single one has ever been identified when tested in vitro against penicillin or amoxicillin. The same thing is true for cephalosporins -- no resistance whatsoever.


    With respect to penicillin-allergic patients, erythromycin was a first-line recommendation in the past. That drug causes a fair amount of gastric distress. Erythromycin has been eliminated from the current guideline and replaced by azithromycin or clarithromycin, which are equivalent in their activity to erythromycin but much better tolerated.


    However, there is some resistance to macrolide antibiotics among GAS. It varies from year to year and from geographic site to geographic site. On average in the United States, 5%-8% of GAS strains are macrolide resistant, at least in the studies that we've done, which are now a few years out of date.[11] But it fluctuates widely, and in real practice a clinician treating a penicillin-allergic patient with strep throat is not going to know the sensitivity of that particular child's strep to this class of antibiotics. That information is not going to be available on a real-time basis. Often, it can only be obtained by specifically asking the microbiology lab to test the organisms, and that takes several days and is not very practical.


    So, having said that, the recommendations for the penicillin-allergic patient do include clarithromycin and azithromycin. I should highlight that the approved dosing for azithromycin in this situation is 12 mg/kg/day once a day for 5 days. Azithromycin is essentially the only agent that is given in a 5-day course as opposed to a 10-day course for all the other agents.


    In addition, clindamycin for 10 days is highly efficacious, and the resistance rate of GAS to clindamycin is around 1%.[11]


    The other potential recommendation for the penicillin-allergic individual is a first-generation cephalosporin with the caveat that you should not administer any cephalosporin to someone who has anaphylactic-type penicillin allergy that includes hives, wheezing, or frank anaphylaxis. If the symptoms attributed to penicillin allergy include only a mild rash of uncertain consequence but not hives, it should be fine to administer a cephalosporin in that situation. Cefadroxil, a first-generation cephalosporin, can be given once daily for 10 days.


    Medscape: Can you review the recommendations for ancillary treatment with other pharmacologic and nonpharmacologic agents? Is there any role for surgery?


    Dr. Shulman: There have been some publications in the last decade that have studied the potential adjunctive value of steroids in treating streptococcal pharyngitis. Our guideline does not endorse the use of steroids even in brief regimens. The trials are less than ideally performed, and our assessment is that the putative benefit is marginal at best. Because GAS pharyngitis is a self-limited illness, symptoms resolve quickly with antibiotic therapy, even more quickly than they do spontaneously. It is hard to demonstrate significant benefit from steroids. So we do not believe that they should play a role.


    On the other hand, nonsteroidal medications could be administered for a short period of time to relieve high fever and severe discomfort and buy some time for the antibiotic to work. We do not believe that that should be a common and routine recommendation but one that should be individualized. I should also note the caveat that we do not recommend the administration of salicylate (aspirin) to children in this circumstance.


    With respect to surgery, there has been much discussion and consideration of tonsillectomy as an intervention in the patient who is having apparent recurrent GAS pharyngitis episodes. The largest and best performed study from Pittsburgh conducted in patients who were thought to have recurrent GAS pharyngitis demonstrated a transient benefit with somewhat fewer pharyngitis episodes in the posttonsillectomy patients, but that benefit was only seen for a year.[12] After that year, the frequency of pharyngitis in the tonsillectomized and nontonsillectomized groups was essentially the same.


    We also are concerned that many patients who are thought to have recurrent GAS pharyngitis are, in fact, the carriers we spoke about earlier who are having recurrent viral illnesses rather than having recurrent bona fide GAS pharyngitis. In any case, we do not feel that this particular surgical intervention is warranted except in very selected circumstances. Therefore, the guideline states that tonsillectomy should not be performed for the sole indication of recurrent streptococcal pharyngitis.





    Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55:e86-e102. http://cid.oxfordjournals.org/content/early/2012/09/06/cid.cis629.full.pdf+html Accessed September 25, 2012.


    Zhang Y, Steinman MA, Kaplan CM. Geographic variation in outpatient antibiotic prescribing among older adults. Arch Intern Med. 2012;172:1-7. http://archinte.jamanetwork.com/article.aspx?articleid=1362924 Accessed September 25, 2012.


    Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National trends in visit rates and antibiotic prescribing for adults with acute sinusitis. Arch Intern Med. 2012;172:1513-1514.


    Gonzales R, Ackerman S, Handley M. Can implementation science help to overcome challenges in translating judicious antibiotic use into practice? Arch Intern Med. 2012;172:1471-1473.


    van Driel ML, De Sutter AIM, Keber N, Habraken H, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis. The Cochrane Library. 2010. http://onlinelibrary.wiley.com/doi/10.1002

    /14651858.CD004406.pub2/abstract;jsessionid=42C4D6A10E51E1B5D005209BA386E455.d03t03 Accessed October 22, 2012.


    Feder HM Jr, Gerber MA, Randolph MF, Stelmach PS, Kaplan EL. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics. 1999;103:47-51. Abstract


    Gerber MA, Tanz RR. New approaches to the treatment of group A streptococcal pharyngitis. Curr Opin Pediatr. 2001;13:51-55. Abstract


    Clegg HW, Ryan AG, Dallas SD, et al. Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin: a noninferiority trial. Pediatr Infect Dis J. 2006;25:761-767. Abstract


    Lennon DR, Farrell E, Martin DR, Stewart JM. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child. 2008;93:474-478. Abstract


    Shvartzman P, Tabenkin H, Rosentzwaig A, Dolginov F. Treatment of streptococcal pharyngitis with amoxycillin once a day. BMJ. 1993;306:1170-1172. Abstract


    Tanz RR, Shulman ST, Shortridge VD, et al. Community-based surveillance in the United States of macrolide-resistant pediatric pharyngeal group A streptococci during 3 respiratory disease seasons. Clin Infect Dis. 2004;39:1794-1801. Abstract


    Paradise JL, Bluestone CD, Colborn DK, Bernard BS, Rockette HE, Kurs-Lasky M. Tonsillectomy and adenotonsillectomy for recurrent throat infection in moderately affected children. Pediatrics. 2002;110:7-15. Abstract






  4. "Perhaps viral trigger-how does abx help that?"



    Some antibiotics have an anti-inflammatory property. The antibodies create the inflammation which creates many of the symptoms. The antibiotics help combat the inflammation thus reducing many of the symptoms.


    My link


    My link


    "My link"


    Hopefully this helps your progress in understanding. Each of has a unique experience it seems, so it is very hard to completely grasp.

  5. I use: Healthy Origins, Probiotic, 30 Billion CFU's from Iherb.


    Blend of 8 probiotics strains 30 Billion CFU's †


    Lactobacillus acidophilus (La-14) 12 Billion CFU's †

    Bifidobacterium lactis (Bl-04) 12 Billion CFU's †

    Lactobacillus casei (Lc-11) 1 Billion CFU's †

    Bifidobacterium breve (Bb-03) 1 Billion CFU's †

    Lactobacillus salivarius (Ls-33) 1 Billion CFU's †

    Lactobacillus plantarum (Lp-115) 1 Billion CFU's †

    Bifidobacterium longum (Bl-05) 1 Billion CFU's †

    Lactobacillus rhamnosus (Lr-32) 1 Billion CFU's

  6. I use: Healthy Origins, Probiotic, 30 Billion CFU's from Iherb.


    Blend of 8 probiotics strains 30 Billion CFU's †


    Lactobacillus acidophilus (La-14) 12 Billion CFU's †

    Bifidobacterium lactis (Bl-04) 12 Billion CFU's †

    Lactobacillus casei (Lc-11) 1 Billion CFU's †

    Bifidobacterium breve (Bb-03) 1 Billion CFU's †

    Lactobacillus salivarius (Ls-33) 1 Billion CFU's †

    Lactobacillus plantarum (Lp-115) 1 Billion CFU's †

    Bifidobacterium longum (Bl-05) 1 Billion CFU's †

    Lactobacillus rhamnosus (Lr-32) 1 Billion CFU's

  7. The daughter (who presents with autism, PANDAS) referred to in this blog was diagnosed with PANDAS by Dr K.




    Abx were used for a short time, but treatment has moved onto an herbal protocol:


    "Here's what we use now:

    Goldenseal (GS) -- 500 mg, 5x per day

    Oil of Oregano (OoO) -- 3 softgels per day

    Berberine complex -- 200 mg, 4x per day


    As needed if bacteria symptoms increase:

    Neem Plus -- 1/2 cap, 4x per day

    Alimed -- 1-2 drops per day


    As needed for acute illness only:

    Olive Leaf Extract (OlLE) -- 200 mg, 4x per day

    Elderberry -- 1/2 cap 3x per day

    (both are pure encapsulations)"


    Thanks! My sweetie has autism as well. I will review all this, so far it looks good. I would love to get of ABX and go with prevention of flares rather than reaction to flares/infections in every situation possible.

  8. Hopefully we are on way out of our latest flare, and I am seriously looking into ways to boost kiddo's immune system through vitamins and homeopathy. What do you guys use that you feel is helpful? She is 10yrs, 60lbs and her current regimen is:


    Keflex 500mg every day

    Kids MV every day (children's one a day)

    'Lil Critters Omega-3 W/D one chew per day (walmart brand)

    Probiotic one per day (Healthy Origins 30 Billion)

    Calcium 600mg W/Vitamin 400IU one a day

    Bright Spark (Impulse control)

    IBU 200mg Twice a day

    Melatonin TR 5mg at bedtime

    Cocunut Oil 17gm


    Future changes:


    I am going to change her MV to this: Nature's Way, Alive! Whole Food Energizer giving her one a day.


    I am also adding in Planetary Herbs OLE Full Spectrum soon and will use it twice a day (still hoping to get off ABX soon :unsure: ).



    So, what do you guys do that you think helps to improve your kiddo's immune system subsequently reducing flares/infections? Thanks!!!

  9. I am wondering if what I am seeing in DD10 NOW is a herx or what??? LLOONNGG story, but my poor girl had to get 3 stitches on the bottom of her foot last Sunday - and in less than 24 hours an infection had spread to her BONE!! Yes!! Osteomyelitis!! :( She was hospitalized for 2 days on IV antibiotics and home now on mega doses of clindamycin and bactrim. Separation anxiety back and INTENSE at times. AND TICS She has not had any tics since IVIG in February, eye fluttering and jaw clenching/teeth grinding... Also dilated pupils again and "fear" look for hours at a time - these symptoms also gone since IVIG.. SOOOO flare or herx??? Can she have a herx if it is not Lyme related (always tested negative.)


    I believe herxing can be related to many conditions. This sounds more like a flare to me, but I am not sure of course.

  10. I have had C-Dif on two occasions and both times were shortly after starting Tindamax which is a cyst buster and will treat biofilms. Anyway, I was kept on antibiotics while treating for C-Dif. Vancomycin was just an antibiotic that was added to protocol.


    More importantly have you seen a Dr. who specializes in TBI yet? The chest pain and difficultly breathing 'air hunger' are both obvious signs of Babesia and I am wondering if she has been tested.





    Tick Borne Illness

  11. This morning I was at local clinic inside the grocery store and a there was a gentleman and his wife there. The gentleman was about my age and having a seizure. I heard his wife say that he had been suffering from a seizure disorder for many years. Trying to get out of the way and be inconspicuous, I asked to go back to a treatment room. The most interesting thing, I heard the nurse practitioner say as the paramedics were working with him that he tested positive for the rapid strep test. :(


    I said many prayers for the gentleman and hope that he will have a full recovery and get over his strep ASAP.




    Unsure about strep and seizures directly, but I know high fevers most definitely can cause seizures. Hope all is well with him.

  12. Sadly, I can relate. I am sure many here can relate to ignorant or dumb docs.


    When my kiddo had her first "episode" that we now assume was related to undiagnosed Chiari at 15 mo, she screamed blood curdling screams non stop for about 5.5 hours---at the 30 min mark we took her to the ER. The hospital spent more time (4.5 hours) trying to prove we had beaten her in the past or had beaten currently than they spent trying to figure out what was actually going on. They put security guards at her ER room door, to make sure we did not flee with her, and would not even address any issues we were concerned about until ALL the x-rays came back negative for abuse.


    THEN she suddenly became a sudden medical emergency because she was screaming bloody murder and they did not know why. Then they insisted on a spinal tap within a few minutes of drawing the blood work and UAs (that we had been begging for for over 4 hours), and before the results were back for those. I denied them the spinal tap, and they tried to guilt me into it stating how urgent it was. I told them if it was truly "urgent" then they would have wanted it 4.5 hours ago----now they would have to wait the 15 more min until the blood work came back and only if there was a good reason could they do the spinal tap. In that 15 min the "light switch" flipped and her screaming stopped. At her age of just over 15 months, they actually sent us home with a colic DX and a piece of paper that stated: "Colic will resolve by 8 mo old" :blink: .


    We were quite relieved to know that 7 mo ago our issue was actually resolved--even before we were aware it was an issue, we had all just apparently missed the memo <insert sarcasm :ph34r::angry: >.


    For this and many many other reasons, I have little to no faith in the medical community.


    Sorry for the obvious sarcasm, kiddo is on a downward spiral, and my humor is very, very, very (did I mention very?) dry right now.

  13. I have a slew of gum and mouth sores that appear when I am under stress. My dentist prescribes chlohexidine (Peridex) as a daily rinse to heal what sores I have, and to keep me from getting as many. It also stings at first, but after I spit it out, the pain that I had prior to rinsing is gone and the sores heal very quickly.

  14. This is what we use, but I do not claim it is the best, perfect or even amazing. It "seems" to do the trick for us. I give her one a day at 3pm since she takes Olive leaf in the AM and PM. I buy it from www.iherb.com for around $20.00 (My link).


    Here is their international shipping page if you are interested: My link




    Healthy Origins Natural Probiotic 30 billion CFU


    Blend of 8 probiotics strains 30 Billion CFU's †


    Lactobacillus acidophilus (La-14) 12 Billion CFU's †

    Bifidobacterium lactis (Bl-04) 12 Billion CFU's †

    Lactobacillus casei (Lc-11) 1 Billion CFU's †

    Bifidobacterium breve (Bb-03) 1 Billion CFU's †

    Lactobacillus salivarius (Ls-33) 1 Billion CFU's †

    Lactobacillus plantarum (Lp-115) 1 Billion CFU's †

    Bifidobacterium longum (Bl-05) 1 Billion CFU's †

    Lactobacillus rhamnosus (Lr-32) 1 Billion CFU's †

  15. Thanks ko's mom. I will look into it.


    Mayzoo- located in Philadelphia Suburb.


    Maybe this one will help or they may help you find the find right person: "If you are unsure of which neighborhood school serves your home or apartment, you can call the District’s Ombudsman Call Center at (215) 400-4000"




    If you find none of those phone numbers help, let me know when we come back online and I will keep looking.

  16. Am I correct in feeling somatization disorder is the new fangled term for hypochondriac?


    Philadelphia ISD + Ombudsman in google came up with this link and I hope it helps: My link


    Not sure if this is correct or not, but here is a name and number (these state they are for the accelerate program, but I hope this person could get you to the right person if this is the right district that is):


    Ombudsman NW Accel

    2111 Eastburn St,

    Phila PA 19138

    (215) 924-8950

    Julita Byrd




    Ombudsman S Accel

    2715 S. Front St,

    Phila PA 19148

    (215) 334-5290

    Beverly Jones


    From this site: My link



    If you are not in Phily ISD, then try google with your school ISD name + ombusman.

  17. When I had migraine headaches (aura no headache) in my 20's, I felt the Imitrex I was using just made it worse. I also tried Elavil which just made me gain weight, but did make me a bit happy :)

    I found something on Feverfew on the American Headache Association at the time, and started using it. I had some episodes while on it, however after 1.5 years I stopped taking it and have only had one or two migraine headaches since.

    I am curious about using for other applications. I had a very good experience with it and no side effects as i recall, but not sure for children,



    I have regular headaches, so I take a combination prep every morning and it does help reduce the frequency/severity. According to all the data, feverfew by itself is "safe" for kiddos over 2 years of age.

  18. Much like Julia said, our school district offers the K12 curriculum, and the school district teaches evolution - but I'll be honest, haven't looked into it at that level yet - just trying to keep our fall back positions open. But it's a very good point to make sure the curriculum matches your values as well as the district requirements.


    We need to investigate more than just religious aspect as well. I was taught some historically inaccurate information in school, and hubby was taught a bunch of incorrect history in an attempt to make America "look good" in almost all instances, when we know America did some less than savory acts through out time. As home schooling parents, we need to try to make sure our kids are getting a decent and accurate education. The last history text book I picked up had quite a few typos in it, and those can be somewhere in between problematic and just annoying depending on the typo.


    I looked into k-12 years ago, but despite their name, in my state they do not start until 3rd grade and kiddo was in first grade at the time. I need to try to re-look into it, but she learns in such an nontraditional manner it becomes a bit problematic to use a structured traditional method.

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