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FOODBORNE ILLNESS-STREPTOCOCCUS

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) The genus Streptococcus are gram-positive microaerophilic cocci that are nonmotile and occur in pairs or chains. Streptococcal group A has been primarily implicated in foodborne transmission to humans; however, outbreaks have occurred involving group G streptococcus.

Specific Substances

    1) Lancefield group A streptococcus (synonym)
    2) Lancefield group D streptococcus
    3) Lancefield group G streptococcus (synonym)
    4) BETA HEMOLYTIC STREPTOCOCCUS FOOD POISONING (synonym)
    5) Streptococcus food poisoning (synonym)
    6) SPOILED FOOD, STREPTOCOCCUS - BETA HEMOLYTIC (synonym)
    7) Food poisoning streptococcus (synonym)

Available Forms Sources

    A) SOURCES
    1) GROUP A STREPTOCOCCUS
    a) Group A streptococci are transmitted to food via food handlers with poor hygiene or who are ill and is considered a major source of food contamination. Food sources include milk (pasteurized and unpasteurized), ice cream, eggs, lobster, corn, ground ham, potato salad, egg salad, conch salad, custard, rice pudding, and shrimp salad. In the majority of outbreaks, food was kept at room temperature for several hours between the time that it was prepared and when consumption occurred (Center for Food Safety and Applied Nutrition (CFSAN), 2012; Linhart et al, 2008; Asteberg et al, 2006; Centers for Disease Control, 1984).
    2) GROUP G STREPTOCOCCUS
    a) An outbreak of group G streptococcal pharyngitis occurred in a group of people who attended a convention and ate at a luncheon during the event. Fifty-seven of 111 conventioneers developed pharyngitis after consuming chicken salad at the luncheon, as compared with 12 of 117 conventioneers who did not attend the luncheon (5 times the attack rate). Throat cultures yielded Lancefield group G beta-hemolytic streptococci in 21 patients, including 17 ill conventioneers, who had eaten at the luncheon, and an ill cook who had not eaten the luncheon but had been primarily responsible for preparing the main portion of the chicken salad served at the luncheon (Stryker et al, 1982).

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) CAUSATIVE ORGANISM
    1) The genus Streptococcus are gram-positive microaerophillic cocci that are nonmotile and occur in pairs or chains. Although the genus consists of several different streptococcal groups (A, B, C, D, F and G) defined by a combination of hemolytic, antigenic, and physiological characteristics, group A is primarily implicated in foodborne transmission to humans; however, outbreaks have occurred involving group G streptococcus. Group A streptococcus consists of one species (S. pyogenes) with 40 antigenic types. Most of group D species have been reclassified as enterococci.
    B) EPIDEMIOLOGY
    1) Exposure is uncommon.
    C) TARGET POPULATION
    1) All individuals are susceptible.
    D) WITH POISONING/EXPOSURE
    1) ACUTE SYMPTOMS
    a) GROUP A: Tonsillitis, pain on swallowing, high fever, headache, nausea, vomiting, abdominal pain, malaise, rhinorrhea. Rarely, a rash may occur. Complications (ie, scarlet fever, rheumatic fever, glomerulonephritis) are rare and the fatality rate is low.
    b) GROUP G: Pharyngitis, fever, cervical lymphadenopathy, headache, chills, myalgia, arthralgia, cough.
    2) ROUTE OF EXPOSURE
    a) GROUP A: Transmitted from food handlers or use of unpasteurized milk. Common food sources include milk (pasteurized and unpasteurized), ice cream, eggs, lobster, corn, ground ham, potato salad, egg salad, custard, rice pudding, and shrimp salad, and in the majority of outbreaks, food was kept at room temperature for several hours between the time that it was prepared and when consumption occurred.
    3) TIME TO ONSET
    a) GROUP A: 1 to 3 days

Laboratory Monitoring

    A) Monitor serum electrolytes in cases of severe vomiting or diarrhea.
    B) For suspected group A streptococcal infections (eg, tonsillitis, high fever, headache, malaise), throat cultures confirm the diagnosis. Nasal cultures or cultures of pus (in the suspected food handler) and cultures of the suspected food can confirm the source of exposure, but these are performed for epidemiologic investigation, not clinical management. Rapid diagnostic tests for group A streptococcus may facilitate rapid confirmation in the presence of an epidemic.

Treatment Overview

    0.4.2) ORAL/PARENTERAL EXPOSURE
    A) MANAGEMENT OF TOXICITY
    1) Treatment is primarily symptomatic and supportive. Initial assessment must reflect the magnitude and type of dehydration. Rapid correction of deficits and careful monitoring of intake and output are essential. Patients with mild fluid deficits can often be managed with oral fluid therapy consisting of clear liquids or specially formulated solutions. Patients with moderate to severe dehydration are generally treated with IV fluids.
    2) Treat fever with antipyretics (acetaminophen or ibuprofen).
    3) ANTIBIOTIC THERAPY: Penicillin is the drug of choice for treatment of streptococcal pharyngitis. For patients allergic to penicillin, a narrow-spectrum cephalosporin (eg, cephalexin, cefadroxil) if the patient does not have a type I hypersensitivity to penicillin, clindamycin, or a macrolide antibiotic (ie, azithromycin, clarithromycin) may be alternative choices.
    a) PENICILLIN V: ADULT DOSE: 500 mg orally 2 or 3 times daily for 10 days. PEDIATRIC DOSE: (27 kg or less) 250 mg orally 2 or 3 times daily for 10 days; (greater than 27 kg) 500 mg orally 2 or 3 times daily for 10 days.
    b) CEPHALEXIN: ADULT DOSE: 500 mg orally every 12 hours for 10 days. PEDIATRIC DOSE: (greater than 1 year of age) 25 to 50 mg/kg/day orally in 2 divided doses (maximum 4 g/day) for 10 days.
    c) CEFADROXIL: ADULT DOSE: 1 g/day orally once daily or in 2 divided doses for 10 days. PEDIATRIC DOSE: 30 mg/kg/day orally in a single dose or in divided doses every 12 hours (maximum 2 g/day) for 10 days.
    d) CLINDAMYCIN: ADULT AND PEDIATRIC DOSE: 20 mg/kg/day orally in 3 divided doses, up to a maximum of 1.8 g/day, for 10 days.
    e) AZITHROMYCIN: ADULT DOSE: 500 mg orally as a single dose on day 1, then 250 mg orally once daily on days 2 through 5. PEDIATRIC DOSE: (2 yr and older) 12 mg/kg once daily, up to a maximum daily dose of 500 mg, for 5 days.
    f) CLARITHROMYCIN: ADULT DOSE: 250 mg orally every 12 hours for 10 days. PEDIATRIC DOSE: (6 months and older) 15 mg/kg/day orally in 2 divided doses (maximum 250 mg twice daily) for 10 days.
    B) DECONTAMINATION
    1) Decontamination is not indicated.
    C) ANTIDOTE
    1) None
    D) PATIENT DISPOSITION
    1) HOME CRITERIA: Patients with pharyngitis and mild diarrhea may be treated on an outpatient basis if compliance will be adequate; close follow-up care is essential.
    2) OBSERVATION CRITERIA: Patients with severe symptoms should be sent to a healthcare facility for observation.
    3) ADMISSION CRITERIA: All patients with significant toxicity, severe dehydration, clinical instability, abnormal electrolyte concentrations, or baseline immunocompromised state should be admitted for intravenous rehydration and antibiotic therapy.
    4) CONSULT CRITERIA: Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    E) PITFALLS
    1) Because early symptoms and signs are nonspecific, they may be attributed to other conditions.
    F) TOXICOKINETICS
    1) The incubation period can vary, from 1 to 3 days (group A streptococci).
    G) DIFFERENTIAL DIAGNOSIS
    1) The differential diagnosis includes other bacterial (eg, E. coli) or nonbacterial (eg, viruses, plants or mushrooms ingestion) causes of acute gastroenteritis; exposure to chemicals (eg, insecticides, pesticides).

Range Of Toxicity

    A) TOXICITY: For group A streptococcus, the infectious dose is less than 1000 organisms.

Clinical Effects

Summary Of Exposure

    A) CAUSATIVE ORGANISM
    1) The genus Streptococcus are gram-positive microaerophillic cocci that are nonmotile and occur in pairs or chains. Although the genus consists of several different streptococcal groups (A, B, C, D, F and G) defined by a combination of hemolytic, antigenic, and physiological characteristics, group A is primarily implicated in foodborne transmission to humans; however, outbreaks have occurred involving group G streptococcus. Group A streptococcus consists of one species (S. pyogenes) with 40 antigenic types. Most of group D species have been reclassified as enterococci.
    B) EPIDEMIOLOGY
    1) Exposure is uncommon.
    C) TARGET POPULATION
    1) All individuals are susceptible.
    D) WITH POISONING/EXPOSURE
    1) ACUTE SYMPTOMS
    a) GROUP A: Tonsillitis, pain on swallowing, high fever, headache, nausea, vomiting, abdominal pain, malaise, rhinorrhea. Rarely, a rash may occur. Complications (ie, scarlet fever, rheumatic fever, glomerulonephritis) are rare and the fatality rate is low.
    b) GROUP G: Pharyngitis, fever, cervical lymphadenopathy, headache, chills, myalgia, arthralgia, cough.
    2) ROUTE OF EXPOSURE
    a) GROUP A: Transmitted from food handlers or use of unpasteurized milk. Common food sources include milk (pasteurized and unpasteurized), ice cream, eggs, lobster, corn, ground ham, potato salad, egg salad, custard, rice pudding, and shrimp salad, and in the majority of outbreaks, food was kept at room temperature for several hours between the time that it was prepared and when consumption occurred.
    3) TIME TO ONSET
    a) GROUP A: 1 to 3 days

Vital Signs

    3.3.3) TEMPERATURE
    A) WITH POISONING/EXPOSURE
    1) FEVER and chills are frequent occurrences with foodborne streptococcal pharyngitis (Asteberg et al, 2006; Matsumoto et al, 1999; Bar-Dayan et al, 1996; Shemesh et al, 1994; Cohen et al, 1987; Berkley et al, 1986a; Decker et al, 1985; Stryker et al, 1982).

Heent

    3.4.6) THROAT
    A) WITH POISONING/EXPOSURE
    1) TONSILLITIS: A severe sore throat is common; exudative tonsillitis, hoarseness, and submandibular adenopathy may be noted (Linhart et al, 2008; Katzenell et al, 2001; Matsumoto et al, 1999; Bar-Dayan et al, 1996; Shemesh et al, 1994).
    2) A sore throat was reported in 95% of patients (n=153) during a group A streptococcal outbreak following consumption of a "sandwich layer" cake, consisting of mayonnaise, ham, eggs, caviar, and meatballs, that had been left unrefrigerated for 24 hours prior to consumption. Onset of symptoms occurred 1 to 2 days after consumption (Asteberg et al, 2006).
    3) PHARYNGITIS was reported following a foodborne group G streptococcal outbreak (Stryker et al, 1982).

Respiratory

    3.6.2) CLINICAL EFFECTS
    A) COUGH
    1) WITH POISONING/EXPOSURE
    a) Cough was reported in 24% of patients (n=17) with culture-confirmed group G streptococcal pharyngitis following a foodborne outbreak (Stryker et al, 1982).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) HEADACHE
    1) WITH POISONING/EXPOSURE
    a) Headache is a common occurrence following streptococcus-associated food poisoning (Shemesh et al, 1994; Berkley et al, 1986) and may also be apparent in cases of streptococcal pharyngitis due to foodborne illness(Matsumoto et al, 1999; Stryker et al, 1982).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) NAUSEA AND VOMITING
    1) WITH POISONING/EXPOSURE
    a) Vomiting was reported in 10% in one outbreak (Decker et al, 1985).
    b) Nausea and vomiting occurred in 6.6% and 4.5% of patients (n=244), respectively, who became ill after consumption of food contaminated with group A streptococcus (Matsumoto et al, 1999).
    c) Nausea and vomiting were reported in 19% of patients (n=153) during a group A streptococcal outbreak following consumption of a "sandwich layer" cake, consisting of mayonnaise, ham, eggs, caviar, and meatballs, that had been left unrefrigerated for 24 hours prior to consumption. Onset of symptoms occurred 1 to 2 days after consumption (Asteberg et al, 2006).
    B) DIARRHEA
    1) WITH POISONING/EXPOSURE
    a) Diarrhea was reported in 25% in one outbreak (Decker et al, 1985).
    b) Abdominal pain and diarrhea were reported in several patients following outbreaks of streptococcus-associated food poisoning and pharyngitis (Linhart et al, 2008; Matsumoto et al, 1999; Shemesh et al, 1994).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) ERYTHEMA NODOSUM
    1) WITH POISONING/EXPOSURE
    a) Erythema nodosum was reported in one patient diagnosed with a foodborne group A streptococcal infection (Takayama et al, 2009).

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) MUSCLE WEAKNESS
    1) WITH POISONING/EXPOSURE
    a) Profound sudden weakness was a common finding in one outbreak (Decker et al, 1985).
    B) MUSCLE PAIN
    1) WITH POISONING/EXPOSURE
    a) Myalgias were reported in 87% in one outbreak (Berkley et al, 1986).
    b) Myalgias were reported in 18% of patients (n=17) with culture-confirmed group G streptococcal pharyngitis following a foodborne outbreak (Stryker et al, 1982).
    C) JOINT PAIN
    1) WITH POISONING/EXPOSURE
    a) Arthralgias were reported in 12% of patients (n=17) with culture-confirmed group G streptococcal pharyngitis following a foodborne outbreak (Stryker et al, 1982).

Immunologic

    3.19.2) CLINICAL EFFECTS
    A) LYMPHADENOPATHY
    1) WITH POISONING/EXPOSURE
    a) In one outbreak, 60% of patients had swollen cervical lymph glands (Cohen et al, 1987).
    b) Cervical lymphadenopathy was reported in 41% of patients (n=17) with culture-confirmed group G streptococcal pharyngitis following a foodborne outbreak (Stryker et al, 1982).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) Monitor serum electrolytes in cases of severe vomiting or diarrhea.
    B) For suspected group A streptococcal infections (eg, tonsillitis, high fever, headache, malaise), throat cultures confirm the diagnosis. Nasal cultures or cultures of pus (in the suspected food handler) and cultures of the suspected food can confirm the source of exposure, but these are performed for epidemiologic investigation, not clinical management. Rapid diagnostic tests for group A streptococcus may facilitate rapid confirmation in the presence of an epidemic.
    4.1.2) SERUM/BLOOD
    A) BLOOD/SERUM CHEMISTRY
    1) Monitor serum electrolytes in cases of severe vomiting or diarrhea.
    4.1.4) OTHER
    A) OTHER
    1) CULTURES
    a) For suspected group A streptococcal infections (eg, tonsillitis, high fever, headache, malaise), throat cultures confirm the diagnosis. Nasal cultures or cultures of pus (in the suspected food handler) and cultures of the suspected food can confirm the source of exposure, but these are performed for epidemiologic investigation, not clinical management (Center for Food Safety and Applied Nutrition (CFSAN), 2012).
    2) OTHER
    a) GROUP A: Rapid diagnostic tests for group A streptococcus may facilitate rapid confirmation in the presence of an epidemic (Berkley et al, 1986).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.1) DISPOSITION/ORAL EXPOSURE
    6.3.1.1) ADMISSION CRITERIA/ORAL
    A) All patients with significant toxicity, severe dehydration, clinical instability, abnormal electrolyte concentrations, or baseline immunocompromised state should be admitted for intravenous rehydration and antibiotic therapy.
    6.3.1.2) HOME CRITERIA/ORAL
    A) Patients with pharyngitis and mild diarrhea may be treated on an outpatient basis if compliance will be adequate; close follow-up care is essential.
    6.3.1.3) CONSULT CRITERIA/ORAL
    A) Consult a poison center or medical toxicologist for assistance in managing patients with severe toxicity or in whom the diagnosis is not clear.
    6.3.1.5) OBSERVATION CRITERIA/ORAL
    A) Patients with severe symptoms should be sent to a healthcare facility for observation.

Monitoring

    A) Monitor serum electrolytes in cases of severe vomiting or diarrhea.
    B) For suspected group A streptococcal infections (eg, tonsillitis, high fever, headache, malaise), throat cultures confirm the diagnosis. Nasal cultures or cultures of pus (in the suspected food handler) and cultures of the suspected food can confirm the source of exposure, but these are performed for epidemiologic investigation, not clinical management. Rapid diagnostic tests for group A streptococcus may facilitate rapid confirmation in the presence of an epidemic.

Oral Exposure

    6.5.1) PREVENTION OF ABSORPTION/PREHOSPITAL
    A) Decontamination is not indicated.
    6.5.3) TREATMENT
    A) MONITORING OF PATIENT
    1) Monitor serum electrolytes in cases of severe vomiting or diarrhea.
    2) For suspected group A streptococcal infections (eg, tonsillitis, high fever, headache, malaise), culture nasal and throat swabs, pus, sputum, blood, and suspected food.
    a) Rapid diagnostic tests for group A streptococcus may facilitate rapid confirmation in the presence of an epidemic.
    B) FLUID/ELECTROLYTE BALANCE REGULATION
    1) INTRAVENOUS REHYDRATION: In the moderately to severely dehydrated patient with normal renal function, initial rehydration should take place over 30 to 45 minutes with normal saline (children: 20 mL/kg; adult: 1 to 2 L). This should be followed by maintenance fluids or a repeat bolus if there is evidence of ongoing hypovolemia.
    2) ORAL REHYDRATION: Although oral rehydration requires careful management and must be administered slowly, this approach is appropriate for patients with mild diarrhea who have normal vital signs and minimal evidence of dehydration, and are willing to take fluids orally. Oral rehydration is not appropriate in children with severe circulatory collapse or intractable vomiting (Finberg, 1982).
    C) ANTIBIOTIC
    1) SUMMARY
    a) Penicillin is the drug of choice for treatment of streptococcal pharyngitis. For patients allergic to penicillin, a narrow-spectrum cephalosporin (eg, cephalexin, cefadroxil) if the patient does not have a type I hypersensitivity to penicillin, clindamycin, or a macrolide antibiotic (ie, azithromycin, clarithromycin) may be alternative choices (Gerber et al, 2009).
    2) PENICILLIN V
    a) ADULT DOSE: 500 mg orally 2 or 3 times daily for 10 days (Gerber et al, 2009).
    b) PEDIATRIC DOSE: (27 kg or less) 250 mg orally 2 or 3 times daily for 10 days; (greater than 27 kg) 500 mg orally 2 or 3 times daily for 10 days (Gerber et al, 2009).
    3) CEPHALEXIN
    a) ADULT DOSE: 500 mg orally every 12 hours for 10 days (Prod Info cephalexin oral capsules, 2008).
    b) PEDIATRIC DOSE: (greater than 1 year of age) 25 to 50 mg/kg/day orally in 2 divided doses (maximum 4 g/day) for 10 days (Prod Info cephalexin oral capsules, 2008).
    4) CEFADROXIL
    a) ADULT DOSE: 1 g/day orally once daily or in 2 divided doses for 10 days (Prod Info cefadroxil oral capsules, 2007).
    b) PEDIATRIC DOSE: 30 mg/kg/day orally in a single dose or in divided doses every 12 hours (maximum 2 g/day) for 10 days (Prod Info cefadroxil oral capsules, 2007).
    5) CLINDAMYCIN
    a) ADULT and PEDIATRIC DOSE: 20 mg/kg/day orally in 3 divided doses, up to a maximum of 1.8 g/day, for 10 days (Gerber et al, 2009).
    6) AZITHROMYCIN
    a) ADULT DOSE: 500 mg orally as a single dose on day 1, then 250 mg orally once daily on days 2 through 5 (Prod Info ZITHROMAX(R) oral suspension, tablets, 2010).
    b) PEDIATRIC DOSE: (2 yr and older) 12 mg/kg once daily, up to a maximum daily dose of 500 mg, for 5 days (Prod Info ZITHROMAX(R) oral suspension, tablets, 2010; Gerber et al, 2009).
    7) CLARITHROMYCIN
    a) ADULT DOSE: 250 mg orally every 12 hours for 10 days (Prod Info BIAXIN(R) Filmtab(R), BIAXIN(R) XL Filmtab(R), BIAXIN(R) extended-release oral tablets, oral suspension, oral tablets, 2009).
    b) PEDIATRIC DOSE: (6 months and older) 15 mg/kg/day orally in 2 divided doses (maximum 250 mg twice daily) for 10 days (Prod Info BIAXIN(R) Filmtab(R), BIAXIN(R) XL Filmtab(R), BIAXIN(R) extended-release oral tablets, oral suspension, oral tablets, 2009; Gerber et al, 2009).
    8) Prompt administration of antibiotics may prevent secondary attacks among household contacts (Ryder et al, 1977; Berkley et al, 1986; Katzenell et al, 2001).

Range Of Toxicity

Summary

    A) TOXICITY: For group A streptococcus, the infectious dose is less than 1000 organisms.

Minimum Lethal Exposure

    A) MORTALITY RATE
    1) STREPTOCOCCUS INFECTION: Most cases of infection are relatively mild; however, patients that have underlying health issues, immunocompromised have an estimated mortality rate of 13% (US Food and Drug Administration, 2009).

Maximum Tolerated Exposure

    A) INFECTIVE DOSE
    1) For group A foodborne streptococcal infections, the infectious dose is less than 1000 organisms (US Food and Drug Administration, 2009).

Pharmacology Toxicology

Toxicologic Mechanism

    A) Streptococcus is gram-positive, catalase negative, microaerophilic cocci that are nonmotile and occur in chains or pairs. Group A has been associated with many virulence factors, such as streptolysin O, streptolysin S, erythrogenic toxin, pyrogenic toxin, streptokinase, superantigens, protein SIC, SpeB, M-protein family, firbronectin-binding proteins, C5a peptidase. However, the mechanism of these factors is not well understood (Center for Food Safety and Applied Nutrition (CFSAN), 2012).

References

General Bibliography

    1) Asteberg I , Andersson Y , Dotevall L , et al: A food-borne streptococcal sore throat outbreak in a small community. Scand J Infect Dis 2006; 38(11-12):988-994.
    2) Bar-Dayan Y, Bar-Dayan Y, & Klainbaum Y: Food-borne outbreak of streptococcal pharyngitis in an Israeli airforce base. Scand J Infect Dis 1996; 28:563-566.
    3) Berkley SF, Rigau-Perez JG, & Facklam R: Foodborne streptococcal pharyngitis after a party. Publ Health Rep 1986; 101:211-215.
    4) Berkley SF, Rigau-Perez JG, Facklam R, et al: Foodborne streptococcal pharyngitis after a party.. Publ Health Rep 1986a; 101:211-215.
    5) Center for Food Safety and Applied Nutrition (CFSAN): Streptococcus Species. In: Bad Bug Book Foodborne Pathogenic Microorganisms and Natural Toxins Handbook Second Edition. U.S. Food and Drug Administration (FDA). College Park, MD. 2012. Available from URL: http://www.fda.gov/downloads/Food/FoodSafety/FoodborneIllness/FoodborneIllnessFoodbornePathogensNaturalToxins/BadBugBook/UCM297627.pdf. As accessed 2013-03-06.
    6) Centers for Disease Control : Streptococcal foodborne outbreaks--Puerto Rico, Missouri. MMWR Morb Mortal Wkly Rep 1984; 33(47):669-672.
    7) Cohen D, Ferne M, & Rouach T: Food-borne outbreak of group G streptococcal sore throat in an Israeli military base. Epidem Inf 1987; 99:249-255.
    8) Decker MD, Lavely GB, & Hutcheson RH Jr: Food-borne streptococcal pharyngitis in a hospital pediatrics clinic. JAMA 1985; 253:679-681.
    9) Finberg L: Oral therapy for dehydration in diarrheal diseases as a global problem (editorial). J Pediatr Gastroenterol Nutr 1982; 1:3-5.
    10) Gerber MA , Baltimore RS , Eaton CB , et al: Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation 2009; 119(11):1541-1551.
    11) Katzenell U, Shemer J, & Bar-Dayan Y: Streptococcal contamination of food; an unusual cause of epidemic pharyngitis. Epidemiol Infect 2001; 127:179-184.
    12) Linhart Y , Amitai Z , Lewis M , et al: A food-borne outbreak of streptococcal pharyngitis. Isr Med Assoc J 2008; 10(8-9):617-620.
    13) Matsumoto M, Miwa Y, & Matsui H: An outbreak of pharyngitis caused by food-borne group A streptococcus. Jpn Infect Dis 1999; 52:127-128.
    14) Product Information: BIAXIN(R) Filmtab(R), BIAXIN(R) XL Filmtab(R), BIAXIN(R) extended-release oral tablets, oral suspension, oral tablets, clarithromycin extended-release oral tablets, oral suspension, oral tablets. Abbott Laboratories, North Chicago, IL, 2009.
    15) Product Information: ZITHROMAX(R) oral suspension, tablets, azithromycin oral suspension, tablets. Pfizer Labs, New York, NY, 2010.
    16) Product Information: cefadroxil oral capsules, cefadroxil oral capsules. Lupin Pharmaceuticals Inc, Baltimore, MD, 2007.
    17) Product Information: cephalexin oral capsules, cephalexin oral capsules. Lupin Pharmaceuticals Inc, Baltimore, MD, 2008.
    18) Ryder RW, Lawrence DN, & Nitzkin JL: An evaluation of penicillin prophylaxis during an outbreak of foodborne streptococcal pharyngitis. Am J Epidemiol 1977; 106:139-144.
    19) Shemesh E, Fischel T, & Goldstein N: An outbreak of foodborne streptococcal throat infection. Isr J Med Sci 1994; 275-278.
    20) Stryker WS, Fraser DW, & Facklam RR: Foodborne outbreak of group G streptococcal pharyngitis. Am J Epidemiol 1982; 116:533-540.
    21) Takayama Y , Hikawa S , Okada J , et al: A foodborne outbreak of a group A streptococcal infection in a Japanese university hospital. Eur J Clin Microbiol Infect Dis 2009; 28(3):305-308.
    22) US Food and Drug Administration: Bad Bug Book: Foodborne Pathogenic Microorganisms and Natural Toxins Handbook Streptococcus spp. US Food and Drug Administration. Silver Spring, MD. 2009. Available from URL: http://www.fda.gov/Food/FoodSafety/FoodborneIllness/FoodborneIllnessFoodbornePathogensNaturalToxins/BadBugBook/ucm070584.htm. As accessed 2011-03-24.