Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Pathophysiology Pharyngitis is an inflammation of the pharynx that can lead to a sore throat. There is arising evidence that delaying antimicrobial therapy by 3 days might not prolong illness recovery39,40 and that laboratory diagnostics cannot adequately differentiate subclinical bacterial carriers.41 The more conservative antimicrobial approach presented by the National Institute for Health and Care Excellence guidelines might be beneficial (Figure 4).38 With a focus on symptom management with close follow-up of cases with low pretest probability and delayed prescriptions in intermediate-risk groups, this strategy might decrease Canadian antibiotic use by as much as the 27% seen in the United Kingdom without increasing complication rates or mortality.41. Background. Bacterial pharyngitis is less common, but it is related to serious complications and sequelae. Corticosteroids as standalone or add-on treatment for sore throat. These frameworks should guide, but not supersede, a physicians clinical judgment. Pharyngitis - PMC - National Center for Biotechnology Information Pharyngitis: Practice Essentials, Background, Pathophysiology - Medscape Cooper RJ, Hoffman JR, Bartlett JG, et al. Federal government websites often end in .gov or .mil. The patients' clinical history and physical examination findings can help distinguish among the several viral, bacterial, and other causes of pharyngitis. Penicillin VK (every 250 mg of penicillin VK = 400,000 U of penicillin), Children >12 years of age: 2550 mg/kg/day orally divided three to four times daily for 10 days (maximum, 3 g/day), Children >12 years of age: 250500 mg orally three or four times daily for 10 days (maximum, 3 g/day), Adults: 250 mg orally three or four times daily or 500 mg orally twice daily for 10 days, Children: 0.30.6 million units intramuscularly (IM) once for children lighter than 27 kg, or 0.9 million units IM once for children heavier than 27 kg, Children: 3050 mg/kg/day orally divided three to four times daily for 10 days, Adults: 250500 mg orally three to four times daily for 10 days, Adults: 400 mg orally four times daily for 10 days, Children: 2550 mg/kg/day orally divided twice daily for 1014 days (maximum, 4 g/day), Adults: 500 mg orally twice daily for 1014 days, Children: 30 mg/kg/day orally divided twice daily for 10 days (maximum, 2 g/day), Adults: 12 g orally divided once or twice daily for 10 days, Children >3 months: 2545 mg/kg/day orally divided twice daily or 2040 mg/kg/day orally divided three times daily for 10 days, Adults: 500875 mg orally twice daily for 10 days, Children: 2030 mg/kg/day orally divided three times daily for 10 days (maximum, 1.8 g/ day), Adults: 150 mg orally four times daily or 300 mg orally twice daily for 10 days, Children >3 months old, but < 40 kg: 2545 mg/kg/day orally divided twice daily or 20 40 mg/kg/day divided three times daily for 10 days Children > 40 kg: dosing similar to adults, Dosing identical to initial treatment options. sharing sensitive information, make sure youre on a federal Bethesda, MD 20894, Web Policies Although viral pharyngitis is typically self-limiting with minimal sequelae, bacterial and fungal infections are more severe. Empirical antibiotic use should be limited to patients who are severely ill, have a high risk of complications, or show no signs of improvement within 5 days of presentation. [ 2] When suspected, bacterial pharyngitis should be confirmed with. Viral features and testing for streptococcal pharyngitis. Pharyngitis is one of the most common conditions encountered by the family physician. In most cases, it is caused by an infection, either bacterial or viral. Useful, well-validated clinical decision rules are available to help family physicians care for patients who present with pharyngitis. Streptococcus pyogenesgroup A streptococcus (GAS)infections (strep throat) occur in up to 30% and 15% of sore throats in pediatric and adult populations, respectively.2 Group A streptococcus infections can have life-threatening complications in less than 0.015% of pediatric and 0.05% of adult patients.4,5 These can be separated into nonsuppurative (acute rheumatic fever, glomerulonephritis, pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) and suppurative (peritonsillar abscess, septic jugular-vein thrombophlebitis, Vincent angina) complications that warrant urgent medical or surgical intervention.2,6. Randel A, Infectious Disease Society of America. Viral infections often include cough, coryza, conjunctivitis, fatigue, hoarseness, generalized body aches, abdominal pain, or diarrhea as additional symptoms. Table 1. Infection with Streptococcus pyogenes (group A beta-hemolytic streptococci) is the most common bacterial cause of acute pharyngitis and is responsible for an estimated 5 to 15% of sore throat cases among adults [ 3] and 20 to 30% of cases among children [ 2, 4 ]. IDSA updates guideline for managing group A streptococcal pharyngitis. Signs and symptoms of group A versus non-group A strep throat: a meta-analysis. Many bacterial and viral organisms are capable of inducing pharyngitis, either as a single manifestation or as part of a more generalized. Although a broad variety of differential diagnoses must be considered, ranging from infectious or inflammatory etiology to traumatic or neoplastic processes, the vast majority of these symptoms derive from either a viral or bacterial source. and transmitted securely. To provide family physicians with an updated approach to diagnosis and treatment of pharyngitis, detailing key symptoms, methods of investigation, and a summary of common causes. Third, the patient's symptoms should be alleviated. The most common cause of a sore throat (pharyngitis) is a viral infection, such as a cold or the flu. 5 GABHS sore throats may lead to severe systemic complications such as acute rheumatic fever and glomerulonephritis as well as suppurative complications such as peritonsillar abscess (quinsy).. EBV is also associated with posterior cervical lymph adenopathy, splenomegaly, and a classic maculopa-pular rash that develops if patients receive penicillin-derived antibiotics. Etiologic agents are passed through person-to-person contact, most likely via droplets of nasal secretions or saliva. [ 1] Kocoglu E, Karabay O, Yilmaz F, Ekerbicer H. The impact of incubating the throat culture for 72 h on the diagnosis of group A beta-hemolytic streptococci. Kawasaki disease is most common in children younger than 3 years of age, and is defined by a number of well-documented features, including pharyngeal erythema, strawberry tongue, nonpurulent conjunctivitis, fever, cervical lymphaden-opathy, cracked red lips, and erythema and swelling of the hands and feet with desquamation of periungual regions several days after symptom onset. Pathophysiology of Pediatric Ear, Nose, and Throat Infections The resultant inflammatory process can damage heart muscle and valves (especially, mitral valves), connective tissue, joints, and the central nervous system. Outbreaks of pharyngitis may occur in households or classrooms, and, infrequently, may be linked to food or animal sources. Copyright 2023 American Academy of Family Physicians. Second, based on the above assessment, the physician must determine which laboratory tests, if any, should be carried out to ensure the proper diagnosis. Anthony R, Flores MTC. Acute tonsillitis may be defined as inflammation of the tonsils, predominantly due to infection. Acute influenza and HIV are the only viruses for which treatments with antiviral agents may improve symptoms. When streptococcal pharyngitis is suspected, the physician should listen for the presence of a heart murmur and evaluate the patient for hepatosplenomegaly. Nakhoul GN, Hickner J. Sore throat caused by pharyngitis is commonly seen in family medicine clinics and is caused by inflammation of the pharynx and surrounding tissues. If patients do not have any other signs of infection or do not respond as expected to treatment of pharyngitis, physicians should investigate noninfectious causes. Penicillin V and rifampin for the treatment of group A streptococcal pharyngitis: a randomized trial of 10 days penicillin vs 10 days penicillin with rifampin during the final 4 days of therapy. FOIA Rapid antigen group A streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis. Does this patient have strep throat? Poststreptococcal glomerulonephritis is thought to result from a reaction between circulating antibody complexes that may inappropriately bind laminin, type IV collagen, and certain proteoglycans found in the kidneys. Empirical validation of guidelines for the management of pharyngitis in children and adults. Pharyngitis | SpringerLink Pharyngitis can present with sudden onset of sore throat, fever, headache, tender anterior cervical lymphadenopathy or lymphadenitis, and, occasionally, abdominal pain, nausea, vomiting, fatigue, or rash. Persistent Sore Throat (Chronic Pharyngitis): Treatment & Symptoms Van Driel ML, De Sutter AIM, Habraken H, Thorning S, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis. Gieseker KE, Roe MH, MacKenzie T, Todd JK. Second-year resident, Department of OtolaryngologyHead and Neck Surgery at the University of Toronto in Ontario. Although viral pharyngitis is typically self-limiting with minimal sequelae, bacterial and fungal infections are more severe. Acute pharyngitis may be caused by a wide variety of microbial agents (Table 1). Dermatologic manifestations in concert with characteristic signs and symptoms serve as diagnostic criteria.13. National Institute for Health and Care Excellence. In the 1990s, more than 6.7 million visits with a primary complaint of sore throat were made by adults to physicians' offices, emergency departments, or other primary care providers in the Unites States.2 Currently, acute pharyngitis accounts for approximately 2% of all primary healthcare visits for adults and 6% for children annually (more than 10 million visits).7,10 Of these cases, approximately 30% are idiopathic, 30 to 60% have a viral etiology, and 5 to 15% are caused by bacteria.8 Of the possible bacterial sources, Group A -hemolytic streptococci (GABHS) is the most frequently isolated pathogen, causing acute pharyngitis in 5 to 15% of adults and 15 to 36% of children in the USA.4,10 Although this chapter reviews the broad range of causes of pharyngitis, the emphasis is on the diagnosis and treatment of GABHS, because this is the only common cause of sore throat that warrants antibiotic treatment. One method for confirming the diagnosis of GABHS pharyngitis is throat culture. Offering a RAD test or throat culture to those patients with two, three, or four of these criteria will help delineate which patients may need antibiotic treatment. Diagnosis of the cause of pharyngitis is primarily achieved using key clinical features seen in the modified Centor or FeverPAIN scoring systems and, sparingly, with rapid antigen detection testing. Common causes of lowered immunity include HIV, diabetes, treatment with steroids or chemotherapy drugs, stress, fatigue, and poor diet. Eaton CA. A confirmatory diagnosis is made by microbacteriologic analysis. Dermatologic features of the disease become apparent within three days of the onset of fever14,18 and include cracked red lips, a generalized polymorphous erythematous rash with edema and erythema of the hands and feet, and periungual desquamation followed by peeling of the palms. The etiology is usually infectious, with most cases being of viral origin and most bacterial. Group A streptococcus (GAS) is the main bacterial cause, and mainly affects children aged 3 to 14 years. Pathogens may directly invade the pharyngeal mucosa as seen in streptococcal pharyngitis or can cause irritation on the pharyngeal mucosa along with increased nasal secretions only . Untreated, GABHS infection lasts seven to 10 days.4,13,19 Patients with untreated streptococcal pharyngitis are infectious during the acute phase of the illness and for one additional week.1 Effective antibiotic therapy shortens the infectious period to 24 hours, reduces the duration of symptoms by about one day, and prevents most complications. The most concerning are S pyogenes infections, which can lead to suppurative and nonsuppurative complications. Kawasaki disease is probably an infectious disease caused by an unknown agent. Acute Pharyngitis | NEJM However, no single element in the history or physical examination is sensitive or specific enough to exclude or diagnose strep throat.1,4 This dilemma has inspired investigators to develop scoring systems to facilitate the diagnostic process.4,18,24, In one study, investigators identified four findings from the history and physical examination that independently predicted a positive throat culture for GABHS in a population of adults and children.26 [Evidence level B, observational study] The findings were tonsillar exudates, anterior cervical lymphadenopathy, absence of cough, and history of fever higher than 38C (100.4F). Rheumatic fever is a clinical diagnosis made using the Jones Criteria, where either two major or one major and one minor criterion are fulfilled. Serology may be collected for presence or absence of streptococcal antibody titers, but this information will not influence the immediate treatment of the patient's pharyngitis symptoms. Symptoms of pharyngitis can include discomfort, dryness, and difficulty swallowing. John R. Bower, in Netter's Infectious Diseases, 2012 Viral Causes of Pharyngitis. Cunha BA. Copyright 2023, StatPearls Publishing LLC. of group A strep pharyngitis is approximately 2 to 5 days. Randel A. AAO-HNS guidelines for tonsillectomy in children and adolescents. Important historical elements include the onset, duration, progression, and severity of the associated symptoms (e.g., fever, cough, respiratory difficulty, swollen lymph nodes); exposure to infections; and presence of comorbid conditions (e.g., diabetes). Conclusion: A thorough history is key to diagnosing pharyngitis. Viral pharyngitis, the most common cause of sore throat, has a wide differential. These include Kawasaki disease, trauma or exertional irritation, neoplastic processes, abscess (such as Ludwig's angina, para-pharyngeal or retropharyngeal, and peritonsillar), thyroiditis, gastroesophageal reflux disease (GERD), or allergy-related postnasal drip.18 Pharyngitis secondary to GERD or allergies would likely accompany symptoms of dyspepsia or nasal congestion with postnasal drip, respectively. The incubation period for Corynebacterium diphtheriae infection is two to four weeks. Physicians must be mindful of the growing problem of antibacterial resistance in this countrypatients who only fulfill one of the Centor Criteria do not need further testing and should not be given antibiotics. Confirm all negative GAS rapid antigen test results in patients < 16 years old with a follow up polymerase chain reaction (PCR) test. She is hoping to obtain an antibiotic prescription to alleviate her symptoms. Pharyngitis is a common concern seen in primary care, caused by viral, bacterial, and fungal agents. [ 1] The absence of pharyngeal inflammation or the presence of rhinorrhea is much more likely to be associated with viral infection. Acute inflammation of the tonsils and pharynx. The 2000 National Ambulatory Medical Care Survey found that acute pharyngitis accounts for 1.1 percent of visits in the primary care setting and is ranked in the top 20 reported primary diagnoses resulting in office visits.3 Peak seasons for sore throat include late winter and early spring.4 Transmission of typical viral and GABHS pharyngitis occurs mostly by hand contact with nasal discharge, rather than by oral contact.7,8 Symptoms develop after a short incubation period of 24 to 72 hours. Sigra S, Hesselmark E, Bejerot S. Treatment of PANDAS and PANS: a systematic review. The pharynx should be examined for erythema, hypertrophy, foreign body, exudates, masses, petechiae, and adenopathy. Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Stewart EH, Davis B, Clemans-Taylor BL, Littenberg B, Estrada CA, Centor RM. The majority of cases are of viral origin and do not require antibiotic treatment. Acute pharyngitis. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Pharyngitis: Causes, symptoms, and treatment Biomarker methods in drug discovery and development. Multiple exotoxins and two hemolysins (Streptolysin S and Streptolysin O) further enhance the virulence of GABHS. Careers, Unable to load your collection due to an error. MIRIAM T. VINCENT, M.D., M.S., NADHIA CELESTIN, M.D., AND ANEELA N. HUSSAIN, M.D. Bacterial pharyngitis, in temperate climates, is more common in winter (or early spring), while enteroviral infection is more common in the summer and fall. Main message The overall incidence would be even less, but patients do not always present for evaluation until complications have begun.4 Signs and symptoms related to abscess formation include a more ill-appearing patient with a hot potato voice, deviation of the uvula or uneven palate, and occasionally a visible fluctuant peritonsillar mass. Vaginal, cervical, penile, and rectal cultures also should be obtained when gonococcal pharyngitis is suspected.27,33. This information is necessary to support a diagnosis of rheumatic fever, but treatment for pharyngitis needs to begin before the return of serology laboratory results. An official website of the United States government. Cheung L, Pattni V, Peacock P, Sood S, Gupta D. Throat swabs have no influence on the management of patients with sore throats. In: Wang F, editor. Other less common causes of pharyngitis include allergies, trauma, cancer, reflux, and certain toxins. government site. Preventing complications requires antimicrobial treatment, but growing antibiotic resistance has placed emphasis on minimizing antibiotic use.7 Unfortunately, differentiating bacterial pharyngitis from other infections is difficult. Of the bacterial causes, only GABHS has an indication for antibiotic therapy. Impact of a stewardship-focused culture follow-up initiative on the treatment of pharyngitis in the emergency department and urgent care settings. sharing sensitive information, make sure youre on a federal The absence of three or four criteria has a negative predictive value near 80%.4,14 The Centor Clinical Prediction Rules are endorsed by the IDSA and listed currently among the CDC recommendations online at: www.cdc/gov/drugresistance/community/files/ads/Acute_Pharyngitis.pdf. OConnor TE, Skinner LJ, Kiely P, Fenton JE. Pharyngitis - PMC - National Center for Biotechnology Information Accessibility If the diagnosis remains uncertain, the physician should consider a test for IgM antibody to the viral capsid antigen. Cohen R, Haas H, Lorrot M, Biscardi S, Romain O, Vie Le Sage F, et al. Airway compromise, hoarseness, or neck swelling may accompany abscesses depending on their location. It is usually caused by viral and/or bacterial infections, such as the common cold and flu (both viral infections) or by infection with the Streptococcus bacterium (strep throat). Serum titers of deoxyribonuclease B, hyaluronidase, strep-tokinase, nicotinic acid, and antistreptolysin O (ASO) may rise quickly during acute streptococcal infection (a positive ASO result reflects a fourfold increase), and will peak within 2 to 3 weeks. Guidelines for the antibiotic use in adults with acute upper respiratory tract infections. First-year resident, Department of OtolaryngologyHead and Neck Surgery at the University of Toronto in Ontario. Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR. Principles of appropriate antibiotic use for acute pharyngitis in adults. Physicians should also have a low threshold for suspecting suppurative complications, as they are life-threatening if untreated. Major criteria include carditis, migratory polyarthritis, Sydenham's chorea, subcutaneous nodules, and erythema marginatum. When evaluating a patient with pharyngitis and outlining a treatment plan, the initial goals of sore throat management must be kept in mind: National Library of Medicine On examination, there is pharyngeal injection with exudates. Streptococcus pharyngitis and pharyngeal carriage: a meta-analysis. A patient presenting with primary HIV may complain of sore throat as well as several other flu-like symptoms, but they are likely to have HIV risk factors in their history (e.g., unprotected intercourse, multiple sexual partners, previous blood transfusion, and intravenous drug use). Minor criteria include fever, arthralgia, elevated acute phase reactants, and a prolonged PR interval on EKG. Assistant Professor and Research Director in the Department of Otolaryngology at Queens University and Adjunct Scientist with ICES Queens. Cet article est disponible en franais. Hence, careful diagnosis of pharyngitis is necessary to provide targeted treatment. Oral corticosteroids for 1 to 2 days have been shown to reduce odynophagia (number needed to treat of 4) but they have no effect on the clinical course.6,42 Lozenges and benzocaine or lidocaine mouth rinses also provide mild pain relief by numbing the oropharynx.10 Nonsteroidal antiinflammatory drugs such as ibuprofen, along with acetaminophen, can be used to reduce pain and fever in adults and children.43 Acetylsalicylic acid is contraindicated in pediatric patients owing to the risk of Reye syndrome.10 Patients suspected of EBV infections should be advised to refrain from contact sports owing to the increased risk of splenic rupture secondary to EBV. The specimen is inoculated onto a 5 percent sheep-blood agar plate, and a bacitracin disk is applied. Physicians should exercise restraint in antibiotic initiation for pharyngitis, as restraint does not delay recovery or increase the risk of S pyogenes infections. Pharyngitis is the inflammation of the mucous membranes of the oropharynx. The tongue may be bright red with a white coating (strawberry tongue).4. She denies recent sick contacts and has not traveled in the past 2 months. Scores below 2 to 3 have up to a 40% chance of streptococcal infection, and risk increases to up to 65% with a score of 4.19 This approach might be equivalent if not superior to the modified Centor score for reducing the need for diagnostic testing and antibiotics without negatively affecting patient outcomes.19. However, clinical impression is only moderately accurate in diagnosing peritonsillar abscess (78 percent sensitivity and 50 percent specificity in one series of 14 patients).20 Intraoral ultrasound examination is an accurate diagnostic test if abscess is suspected. The most widely accepted of these tools is the Centor Clinical Prediction Rules for the diagnosis of GABHS in adults, which uses the presence (or absence) of four main criteria (see Table 2.1).4,12, Presence of 01 of the aboveno further testing indicated, Presence of 24 of the aboveGABHS testing indicated. This article focuses on infectious causes of sore throat (pharyngitis). Dumkow LE, Axford KL, Suda KJ, Draper HM, Brandt KL. Traitement antimicrobien des infections ORL. Adapted from the National Institute for Health and Care Excellence.38, Traditionally, there has been a low threshold for treating pharyngitis owing to the risks of bacterial complications. Family physician in the Department of Family Medicine at Queens University in Kingston, Ont. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. Pharyngitis - PMC Ultimately, the usefulness of clinical prediction rules depends on the prevalence of disease in a given community. Antibiotic treatment of children with sore throat. Pathophysiology of Pharyngitis | PDF | Rtt | Immunology - Scribd official website and that any information you provide is encrypted Eighty percent of cases are caused by viral agents, while the remaining are bacterial and, rarely, fungal infections3 (Table 1). Values from McIsaac et al.18. Patients present with hematuria and, frequently, edema in the setting of a recent streptococcal infection with an elevated antistreptolysin-O titer. Tanz RR, Shulman ST, Barthel MJ, Willert C, Yogev R. Penicillin plus rifampin eradicates pharyngeal carriage of group A streptococci. This activity reviews the evaluation and treatment of patients with pharyngitis and highlights . Gonzalez RM, Varnum SM, Zangar RC. PDF Treatment of Acute Pharyngitis The viruses and other nonstreptococcal bacteria that also can cause pharyngitis are discussed in greater detail below, in the Differential Diagnosis section. Pharyngitis is . Shaikh N, Swaminathan N, Hooper EG. The physician must narrow the differential, decide which clinical and laboratory data may be helpful, select the most appropriate management plan for the patient's symptoms and disease process, and prevent further complications. Antibiotic stewardship and the low incidence of streptococcal pharyngitis complications suggest that treatments can be largely supportive. Tonsillopharyngitis - Ear, Nose, and Throat Disorders - MSD Manual The site is secure. The https:// ensures that you are connecting to the As a library, NLM provides access to scientific literature. Rapid antigen detection tests should be reserved for concerns about antibiotic initiation. All Rights Reserved. Candidiasis (oropharyngeal). The Centor Criteria is an effective clinical tool that may help guide this decision. The most concerning are. Summary of common signs and symptoms of viral, bacterial, and fungal pharyngitis: Signs and symptoms of bacterial pharyngitis can overlap with those of streptococcal pharyngitis. These point-of-care tests detect bacterial and viral antigens from throat swabs taken from tonsillar exudates or the posterior oropharynx using dipsticks. However, there are several other bacterial causes, including Group C streptococci, Neisseria gonorrhorea, Corynebacterium diphtheriae, Mycoplasma pneumoniae, Chlamydia pneumoniae, and Arcanobacterium haemolyticus.3 Clinical presentation and associated signs and symptoms are important for differentiating these bacterial infections. The .gov means its official. The absence of tender anterior cervical adenopathy, tonsillar enlargement, and tonsillar or pharyngeal exudate was most useful in ruling out GABHS. Rheumatic fever is exceedingly rare in the United States and other developed countries (annual incidence less than one case per 100,000).21 This illness should be suspected in any patient with joint swelling and pain, subcutaneous nodules, erythema marginatum or heart murmur, and a confirmed streptococcal infection during the preceding month. are particularly common in children and young adults and are primarily caused by viruses or. Severely ill patients should be referred immediately to the hospital or urgent care for immediate management and workup.
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