3/5/2020 Throat Swab- ClinicalKey

PROCEDURE VIDEOS

Throat Swab

Last Reviewed Date: 5/16/2017

Editors: Debra Weiner, MD, PhD

Contributors: Debra Weiner, MD, PhD, Alexander McAdam, MD,

Todd Thomsen, MD

Medical Writer: Donna Coffman, MD

CPT codes
87070 Culture, bacterial; any other source except urine, blood, or
stool, aerobic, with isolation and presumptive identification of isolates
87081 Culture, presumptive, pathogenic organisms, screening only

FULL DETAILS
PRE-PROCEDURE
INTRODUCTION
Throat swab is one of the most commonly performed procedures in
pediatric patients in emergency departments and in primary care
facilities. A diagnosis of group A beta-hemolytic streptococcal
(GABHS) pharyngitis is the most common indication for performing

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the procedure. Less commonly, it is performed to test for

pharyngitis due to Neisseria gonorrhoeae. Throat swab also
can be performed to diagnose Corynebacterium diphtheriae.

INDICATIONS
Diagnosis of GABHS pharyngitis (i.e., strep throat)

GABHS accounts for 15% to 30% of cases of pharyngitis

in children ages 5 to 15 years, and for 5% to 10% of cases in
adults.1,2 Given that the sensitivity and specificity of
history and examination in children are inadequate to
diagnose GABHS based on clinical findings, and that
children have a higher risk of rheumatic fever than adults,
testing should be considered for patients with pharyngeal
erythema and/or exudate, particularly those who do
not have obvious signs of viral illness (i.e., conjunctivitis,
rhinorrhea, cough, hoarse voice, vesicles, cough).3,4 Only
patients with a positive GABHS rapid test or culture
should be treated.5

Reasons to diagnose and treat GABHS include (1) to

prevent suppurative complications and rheumatic fever;
(2) to reduce duration of illness and severity of symptoms;
(3) to prevent transmission of disease; and (4) to reduce
antibiotic overuse. Treatment does not prevent
glomerulonephritis.

Repeat throat swab in patients who are asymptomatic

after treatment because GABHS usually is not indicated
unless the patient has a history of rheumatic fever or has
GABHS during an epidemic of rheumatic fever or post-
strep glomerulonephritis.5

Diagnosis of gonococcal pharyngitis in sexually active patients,

particularly those with a history of oral sex, or patients for
whom there is a concern for sexual abuse.

Diagnosis of diphtheria: Diphtheria is rare in the United

States (0-5 cases per year), endemic in third-world countries,
and epidemic in countries of the former Soviet Union.

CONTRAINDICATIONS
No contraindications are known.

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Equipment
Sterile throat swabs, polyester (Dacron), rayon, or polyurethane
—one if for culture only, two if for rapid test and culture ( Figure
1)

Transport tube with media (liquid Stuart or liquid Aimes for

GABHS or Neisseria gonorrhoeae ) or without media if GABHS

Alternatively, samples may be sent on culture plate with

appropriate agar (e.g., for GABHS, sheep blood agar 5%;
for N. gonorrhoeae, Thayer-Martin [Becton, Dickson and
Company, Sparks, MD] or JEMBEC [Becton, Dickson and
Company]). Samples on Thayer-Martin require
CO2incubation within 15 minutes, and JEMBEC plates
come with a CO2-releasing tablet in a foil packet. Plates
should be warmed to 35°C before inoculation.

Figure 1 Equipment needed for procedure includes sterile

throat swabs, transport tube, and tongue depressor.

Tongue blade

Gloves and mask are optional but

recommended.**UNIVERSAL PRECAUTIONS**

ANATOMY
Streptococcal pharyngitis

Streptococcal pharyngitis is suggested by tonsillar

enlargement, erythema, exudates, palatal petechiae,

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and anterior cervical adenopathy. Erythema is the most

common finding, and the finding of palatal petechiae is
the most specific.

Patients usually have fever, sometimes have headache,

and often have abdominal pain, which in some cases
precedes the onset of sore throat by 24 to 48 hours.

Patients usually do not have rhinorrhea, congestion, or

cough.

Patients who have had a tonsillectomy are much less likely

to have streptococcal pharyngitis.

Gonococcal pharyngitis

Patients with gonococcal pharyngitis may have

erythema and/or exudates or normal-appearing tonsils
and posterior pharynx. Classic findings of diphtheria
include adherent tonsillar and/or posterior pharynx
exudate and marked anterior cervical adenopathy.

PROCEDURE
Throat swab may be performed with the child sitting or
supine on the bed.

The sitting position is preferred because it allows better

visualization and access to the tonsils and the posterior
pharynx. It may be helpful to have patients who are sitting rest
their head against the raised head of the bed or to have infants
and young children sit in bed on the caregiver's lap or between
the caregiver's legs.

Restraint

Although the procedure is not painful, even the most

cooperative pediatric patients, including older children
and adolescents, are likely to find it objectionable and may
require restraint. Warn caregivers, particularly of young
children, that the child may vomit.

For infants and toddlers, it often is adequate to have an

assistant—either a health care provider or a caregiver—
restrain the head only, particularly if your body is
impeding the child's ability to bring hands to mouth as you

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stand over him. Older school-age children and teens may

require only gentle restraint of the hands.

For children who require restraint of both the hands and

the head, have the child rest the arms on the torso if lying
supine; if sitting, have him rest the hands in his lap and
his head against the bed. Have an assistant use one of his
or her arms or hands to restrain the child's arms, and use
the other hand to apply gently pressure to the forehead to
immobilize the head against the bed. An alternative is to
have the assistant hold the child's arms above and firmly
against the child's head ( Figure 2 ).

If the child is sitting on the caregiver's lap or between his

or her legs, have the caregiver wrap one arm around the
child's arms and body, and hold the child's head against
his or her chest with the other hand ( Figure 3 ).

Figure 2 Restraint of the child. An alternative is to have the

assistant hold the child’s arms above and firmly against the
child’s head.

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Figure 3 Restraint of the child. Caregiver can wrap one arm

around the child’s arms and body and can hold the child’s head
against his or her chest with the other hand.

Open the kit, and remove the swabs.

Have the child open his mouth, or assist him in doing so.

In the cooperative child, this can be accomplished most easily

by instructing him to open his mouth, stick out his tongue, and
say, "aah." This also decreases the gag reflex ( Figure 4 ).

In the uncooperative patient, particularly the child who is

crying, take advantage of the opportunity to insert the tongue
depressor while the mouth is open. As necessary, assist the
child with mouth opening by inserting and gently rotating the
tongue depressor, by palpating inferior to the angle of the jaw,
and/or by squeezing the nares to occlude the nasal airway.

Depress the tongue with the tongue depressor to allow

visualization and access to the tonsils and the posterior
pharynx. In young children, if depressing the tongue is not
successful, it may be necessary to induce a gag reflex, which in
most cases will allow visualization and access, but may cause
the child to vomit. Usually, you have obtained your sample
before the child vomits, but if not, abort the procedure. Any
child who is vomiting should be repositioned rapidly to protect
the airway.

Swab the tonsils or the tonsillar fossa if the tonsils have been
removed and the posterior pharynx, particularly the exudative

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patches, with one swab if for culture only, and both swabs
simultaneously if for rapid test and culture, while rolling the
swabs to ensure that all surfaces of the swab contact the tonsils
and the pharynx. Avoid contact with the soft palate, uvula,
tongue, buccal mucosa, and lips6 ( Figure 5 ).

Figure 4 Instruct the child to open mouth, stick out tongue, and say,
“aah.”

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Figure 5 Swab the tonsils, or the tonsillar fossa, and the posterior
pharynx, particularly exudative patches. Avoid contact with the soft
palate, uvula, tongue, buccal mucosa, and lips.

Clinical Pearls:

Ensuring that all surfaces of the swab have had contact with tonsils
and/or the pharynx ensures that if plated for culture, a surface that
has contacted the tonsils and the posterior will contact the plate.

POST-PROCEDURE
POST-PROCEDURE CARE
If transporting specimen in the transport tube:

Remove the cap from the transport tube.

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Insert the swab(s) into the transport tube so the cap that is
holding the swab(s) fits firmly onto the tube ( Figure 6 ).

Figure 6 Insert the swab(s) into the transport tube so the cap
that is holding the swab(s) fits firmly onto the tube.

If transporting specimen on culture plate:

Roll the swab over the surface of the plate in a zigzag

pattern, rotate the plate 90 degrees, and repeat.

For the JEMBEC plate, add a CO2-releasing tablet.

Label immediately, and send to the lab for rapid streptococcal

antigen test and/or culture as soon as possible. Follow kit or
culture plate instructions and/or the recommendations of your
laboratory for sample handling and transport.

The rapid strep test takes minutes. Sensitivity of the test is 70%
to 90% or slightly higher, and specificity is greater than 95%,
depending on the test used. Rapid strep if performed and
negative should be followed up with culture—the gold
standard.7,8 The sensitivity of a properly performed culture is
90% to 95%.7

Results take 24 to 48 hours. Culture can be performed instead

of rapid strep screening and has been recommended as the
most cost-effective choice if results can be obtained within 48
hours.

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Gonococcal pharyngitis should be diagnosed only by

culture. Rapid testing, although specific for urethral and
vaginal specimens, has low specificity for pharyngeal
samples.

COMPLICATIONS
Most patients will gag.

A few patients will vomit.

Oral trauma is a rare complication. Scant bleeding from friable

infected tonsillar tissue is the most likely type of oral trauma.
Other oral trauma can be avoided by appropriate restraint.

REFERENCES
1. Komaroff AL, Pass TM, Aronson MD, et al: The prediction of
streptococcal pharyngitis in adults. J Gen Int Med 1986; 1: pp. 1.

2. Poses RM, Cebul RD, Collins M, Fager SS: The accuracy of

experienced physicians' probability estimates for patients with sore
throats: implications for decision making. JAMA 1985; 254: pp. 929.

3. Bisno AL, Gerber MA, Gwaltney JM, et al: Practice guidelines for the
diagnosis and management of group A streptococcal pharyngitis . Clin Infect
Dis 2002:35:113.

4. Lin MH, Fong WK, Chang PF, et al: Predictive value of clinical features
in differentiating group A beta hemolytic streptococcal pharyngitis in children ..
J Microbiol Immunol Infect 2003; 36: pp. 21.

5. American Academy of Pediatrics: Group A streptococcal infections

In Pickering LK (ed): The Red Book: 2006 Report of the Committee
on Infectious Diseases, 27th ed, Elk Grove, IL, American Academy of
Pediatrics, 2006, pp 610-616.

6. Fox JW, Marcon MJ, Bonsu BK: Diagnosis of streptococcal pharyngitis

by detection of Streptococcus pyogenes in posterior pharyngeal versus oral
cavity specimens .. J Clin Microbiol 2006; 44: pp. 2593.

7. Gerber MA: Comparison of throat cultures and rapid strep tests for
diagnosis of streptococcal pharyngitis .. Pediatr Infect Dis J 1989; 8: pp.
820.

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8. Gieseker KE, Mackenzie T, Roe MH, Todd JK: Comparison of two

rapid Streptococcus pyogenes diagnostic tests with a rigorous culture
standard .. Pediatr Infect Dis J 2002; 21: pp. 922.

9. Bell LM, Tsarouhas N: Obtaining biologic specimens. In King C,

Henretig FM, King BR, et al (eds): Textbook of Pediatric Emergency
Procedures, 2nd ed, Baltimore, Lippincott Williams & Wilkins, 2007
pp 1129-1136.

10. Bisno AL: Acute pharyngitis .. N Engl J Med 2001; 344: pp. 205.

11. Centers for Disease Control and Prevention: Acute pharyngitis in

adults. Available at http://www.cdc.gov/drugresistance/community/hcp-info-
sheets/adult-acute-pharyngitis.pdf. Accessed October 16, 2008 .

12. Centers for Disease Control and Prevention: Diphtheria.

Available at http://www.cdc.gov/ncidod/DBMD/diseaseinfo/diptheria_t.htm.
Accessed October 16, 2008 .

13. Centers for Disease Control and Prevention: Treat only proven
GAS: physician information sheet (Pediatrics). Available at
http://www.cdc.gov/drugresistance/community/hcp-info-sheets/child-
pharyngitis.htm. Accessed October 16, 2008 .

14. Dajani A, Taubert K, Ferrieri P: Treatment of acute streptococcal

pharyngitis and prevention of rheumatic fever: a statement for health
professionals .. Pediatrics 1995; 96: pp. 758.

15. Ebell MH, Smith MA, Barry HC, et al: Does this patient have strep
throat? .JAMA 2000; 284: pp. 2912.

16. Gunnarsson RK, Holm SE, Soderstrom M: The prevalence of beta-

hemolytic streptococci in throat specimens from healthy children and adults:
implications for the clinical value of throat cultures .. Scand J Prim Health
Care 1997; 15: pp. 149.

17. Snellman L, Stang H, Stang J, et al: Duration of positive throat

cultures for group A streptococci after initiation of antibiotic
therapy. Pediatrics 1993; 96: pp. 758.

18. Vogeley E, Saladino R: Pharyngeal procedures. In King C,

Henretig FM, King BR, et al (eds): Textbook of Pediatric Emergency
Procedures, 2nd ed, Lippincott Williams & Wilkins, 2007, pp 631-
632.

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19. Wald ER: Approach to diagnosis of acute infectious pharyngitis

in children and adolescents. Up To Date, May 2008.

*Recommended highly by the author as an excellent source for

further reading.

Copyright © 2020 Elsevier, Inc. All rights reserved.

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