Strep Throat (Streptococcal Pharyngitis)
• Abrupt onset of sore throat, fever, malaise, nausea, and headache
• Throat red and swollen, with or without exudation
• Tender lymph nodes along the neck
• Positive rapid detection of streptococcal antigen
• Group A streptococci on throat culture
Over 90% of sore throats are caused by viruses. Nonetheless, if you have a sore throat, we recommend consulting a physician to rule out strep throat (group A beta-hemolytic streptococci pharyngotonsillitis or GABHS). You simply cannot tell the difference between the two just by looking at the throat and tonsils. Strep throat is more common in children, with about 15% to 36% of children with sore throats seeking medical care turning out to be positive for strep. Slightly lower percentages occur in adults. However, it must be kept in mind that 10% to 25% of the general population are carriers for group A streptococci; therefore, the true number of cases of sore throat due to strep is probably less than reported. In other words, some people have strep present all of the time in their throat and do not have an active infection.
Diagnostic Considerations
There are now tests available in doctors’ offices that provide an immediate or rapid screening for strep. These tests detect the presence of group A streptococcal antigens and are a major clinical advancement that helps to prevent unnecessary prescribing of antibiotics. Prior to these tests doctors had to rely on throat cultures that usually took two days to show results. Often antibiotics were started before the results were known, leading to unnecessary exposure to antibiotics and a greater likelihood of development of antibiotic-resistant organisms. Rapid strep screening will someday soon replace throat culture as the diagnostic gold standard. That said, these tests remain underutilized, as one analysis found they were performed on only 53% of patients with acute sore throat for whom an antibiotic was prescribed.1
Therapeutic Considerations
From a natural medicine perspective, the primary therapeutic consideration is improving the status of the immune system. If the person’s immune system is functioning well, the illness will be short-lived. Enhancing general immune function, as described in the chapter “Immune System Support,” may shorten the course of the sore throat. In cases of poor immune function, every effort should be made to strengthen the immune system by following the recommendations in that chapter.
While many physicians continue to rely on antibiotics in the treatment of strep throat, in most cases antibiotics are not necessary. Strep throat is usually a self-limiting disease—meaning that it will resolve on its own with time—and most research has shown that clinical recovery is similar in cases in which antibiotics are prescribed and those in which they are not.2–4
The primary concern about not using antibiotics is the development of what is called nonsuppurative poststreptococcal syndromes (rheumatic fever, poststreptococcal glomerulonephritis, etc.). However, antibiotic administration does not significantly reduce the incidence of these complications. The issue seems to be related to a combination of host defense factors and the particular strength (virulence) of some group A strep bacteria that are more likely to cause rheumatic fever and glomerulonephritis.5 It is also important to point out that although many physicians believe that acute rheumatic fever can be caused only by group A strep infection of the upper respiratory tract, population-based studies indicate that strep infections of the skin are the major cause in high-incidence communities. In contrast, in settings in which rheumatic fever has become rare, the group A streptococcal strains causing pharyngitis are of relatively lower virulence in terms of causing rheumatic fever.5
At this time, it appears that the use of antibiotics should be reserved for those who are suffering from severe infection, those whose sore throat is unresponsive to therapy (i.e., no response after one week of immune-supportive therapy), and those with a prior history of rheumatic fever or glomerulonephritis.
If antibiotics are used or have been used, it is important to use a probiotic supplement containing Lactobacillus and Bifidobacterium species. Probiotic supplementation is very important for preventing and treating antibiotic-induced diarrhea, candida overgrowth, and urinary tract infections. Although it is commonly believed that acidophilus supplements are not effective if taken during antibiotic therapy, research actually supports the use of L. acidophilus during antibiotic administration.6,7 Reductions of friendly bacteria and/or superinfection with antibiotic-resistant flora may be prevented by administering L. acidophilus products during antibiotic therapy. A dosage of at least 15 billion to 20 billion organisms is required during antibiotic usage. We recommend taking the probiotic supplement as far between antibiotic doses as possible. After the antibiotic course is finished, a dosage of 2 billion to 5 billion live organisms is usually sufficient.
Vitamin C
During the 1930s there was considerable interest in the relationship between malnutrition and the development of the complications of strep throat. Both experimental animal work and population-based surveys demonstrated a correlation between vitamin C deficiency and the development of these complications. Rheumatic fever is virtually nonexistent in the tropics, where vitamin C intake is higher; and 18% of children in high-risk groups have subnormal serum vitamin C levels.8,9
Vitamin C supplementation of strep-infected, vitamin-C-deficient, rheumatic-fever-susceptible guinea pigs totally prevents the development of rheumatic fever.8,9 Uncontrolled clinical studies demonstrated very positive results when children were given orange juice supplementation. Unfortunately, this promising line of research appears to have been dropped, probably owing to the advent of supposedly effective antibiotics.
The guidelines for enhancing the immune system, as presented in the chapter “Immune System Support,” are particularly well indicated for streptococcal pharyngitis. In addition, the botanicals goldenseal (Hydrastis canadensis) and Echinacea species are well respected in the support of the immune system during strep infections. The berberine alkaloid of goldenseal exerts antibiotic activity against streptococci and, perhaps more important, has been shown to inhibit the attachment of group A streptococci to pharyngeal epithelial cells. Echinacea also exerts action against streptococci infection. To promote the spread of colonies, streptococci secrete large amounts of hyaluronidase. This enzyme is inhibited by echinacea as well as by many bioflavonoids. Echinacea also inactivates group A streptococci and reduces the pro-inflammatory response to strep infection10 as well as promoting greater ability of white blood cells to identify and destroy bacteria.
Extracts of this African plant (Pelargonium sidoides) have been shown to exert a number of effects beneficial in upper respiratory tract infections, particularly acute bronchitis, an indication for which it is an approved drug in Germany (see the chapter “Bronchitis and Pneumonia”). A special extract of P. sidoides known as EPs 7630 or Umcka has demonstrated immune-enhancing effects as well as antibacterial effects and the ability to prevent adhesion of bacteria to epithelial cells.11 In a double-blind study, 143 children ages six to ten with non-GABHS sore throat were given either EPs 7630 or a placebo for six days. Treatment with EPs 7630 reduced the severity of symptoms (the decrease in the severity score from day 0 to day 4 was 7.1 points with EPs 7630 and 2.5 points in the placebo group) and shortened the duration of illness by at least two days, consistent with the results seen in acute bronchitis.12 Although this study addressed non-GABHS sore throat, it does raise the possibility that P. sidoides may have benefit for GABHS.
QUICK REVIEW
• More than 90% of all sore throats are caused by viruses.
• If you have a sore throat, see a physician to rule out strep throat as the cause.
• Before antibiotics are used, an in-office rapid strep screening test should be performed.
• If antibiotics are used or have been used, it is important to use a probiotic supplement containing Lactobacillus acidophilus and Bifidobacterium bifidus.
• Vitamin C is very important in the prevention of rheumatic fever.
• Goldenseal prevents the adherence of strep bacteria to the lining of the throat.
• Echinacea inactivates group A strep and reduces the pro-inflammatory response to strep infection.
TREATMENT SUMMARY
For further information, consult the chapter “Immune System Support.” If antibiotics are used, follow the recommendations for Lactobacillus acidophilus supplementation in the chapter “Diarrhea.”
• A high-potency multiple vitamin and mineral formula as described in the chapter “Supplementary Measures”
• Key individual nutrients:
Vitamin C: 500 to 1,000 mg every two waking hours
Vitamin A: 5,000 IU per day (women who are pregnant or who may become pregnant should take no more than 3,000 IU per day)
Zinc: 30 mg per day
• One of the following:
Grape seed extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Pine bark extract (>95% procyanidolic oligomers): 100 to 300 mg per day
Mixed citrus bioflavonoids: 1,000 mg per day
One or more of the following can be used:
• Echinacea species:
Fluid extract of the fresh aerial portion of E. purpurea (1:1): 2 to 4 ml (1/2 to 1 tsp) three times a day (preferred form)
Juice of aerial portion of Echinacea purpurea stabilized in 22% ethanol: 2 to 4 ml (1/2 to 1 tsp) three times a day (preferred form)
Dried root (or as tea): 1 to 2 g three times a day
Freeze-dried plant: 325 to 650 mg three times a day
Tincture (1:5): 2 to 4 ml (1/2 to 1 tsp) three times a day
Fluid extract (1:1): 2 to 4 ml (1/2 to 1 tsp) three times a day
Solid (dry powdered) extract (6.5: 1 or 3.5% echinacoside): 150 to 300 mg three times a day
• Goldenseal (Hydrastis canadensis), standardized extracts recommended:
Dried root or as infusion (tea): 2 to 4 g three times a day
Tincture (1:5): 6 to 12 ml (1.5 to 3 tsp) three times a day
Fluid extract (1:1): 2 to 4 ml (0.5 to 1 tsp) three times a day
Solid (powdered dry) extract (4:1 or 8% to 12% alkaloid content): 250 to 500 mg three times a day
• South African geranium (Pelargonium sidoides, EPs 7630 or equivalent preparation): adults, 3 ml three times per day or two 20-mg tablets three times per day for up to 14 days; children ages 7 through 12, 30 drops (1.5 ml) three times per day; age 6 years or less, 10 drops (0.5 ml) three times per day