eMedicine Specialties > Infectious Diseases > HEENT Infections

Pharyngitis, Bacterial: Follow-up

Author: Eric S Halsey, MD, Chief, Department of Infectious Diseases, Wright-Patterson Air Force Base; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Assistant Professor of Medicine, Wright State University
Contributor Information and Disclosures

Updated: May 19, 2009

Follow-up

Further Inpatient Care

  • Droplet precautions should be observed until 24 hours after the initiation of antibiotics.

Further Outpatient Care

  • Patients with bacterial pharyngitis should be kept out of daycare, school, or work until 24 hours after the initiation of antibiotics.

Complications

GABHS infection may result in suppurative or nonsuppurative complications.

  • Local complications: These result from untreated infection that spreads to adjacent sites. Some of the more common of these suppurative infections include retropharyngeal abscess, peritonsillar abscess, sinusitis, cervical lymphadenitis, otitis media, and mastoiditis.
  • Acute rheumatic fever: This disorder usually occurs 2-4 weeks after an episode of pharyngitis. Administration of proper antibiotics up to 9 days after the onset of pharyngeal symptoms has been shown to prevent this manifestation.38 Major manifestations of acute rheumatic fever include carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules. Minor criteria include fever, polyarthralgia, elevated leukocyte count, elevated erythrocyte sedimentation rate, and prolonged P-R interval.
  • Rheumatic heart disease: This is the chronic valvular manifestation of acute rheumatic fever. The mitral valve is the site most often affected, and either regurgitation or stenosis may result.39 In individuals with rheumatic heart disease, long-term secondary prophylaxis, often with benzathine penicillin, decreases the risk of subsequent episodes of acute rheumatic fever and further heart damage.
  • Poststreptococcal glomerulonephritis: This usually occurs 1-3 weeks following GABHS pharyngitis. Poststreptococcal glomerulonephritis, which may also follow a GABHS skin infection, has not been shown to be preventable with proper administration of antibiotics. Patients often present with hematuria, edema, and hypertension.

Prognosis

  • GABHS pharyngitis is usually a self-limited illness. Throat symptoms resolve within 3-4 days in untreated patients. Administration of penicillin shortly after disease onset may shorten symptoms by 1-2 days.40

Patient Education

  • Symptomatic relief may be provided by warm saline gargles, throat lozenges, and ibuprofen.
  • Patients with bacterial pharyngitis should be instructed to complete a full course of antibiotics, even if symptoms resolve.
  • For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education articles Tonsillitis and Sore Throat.

Miscellaneous

Medicolegal Pitfalls

  • Narrow-spectrum agents are preferred for the treatment of GABHS pharyngitis. Broad-spectrum antibiotics confer no added antimicrobial advantage but may result in increased cost, adverse effects, and alteration of normal host flora. For similar reasons, antibiotics should not be continued or prescribed to patients with negative GABHS test results unless another bacterial etiology is suspected or confirmed.
  • Other treatable bacterial causes of pharyngitis should be considered in those in whom GABHS test results are negative (see Causes).
  • Acute retroviral syndrome, the earliest clinical manifestation of HIV infection, goes undiagnosed in most cases.41 In addition to fever, malaise, and rash, pharyngitis is one of the most common findings. In at-risk patients in whom GABHS test results are negative, the diagnosis may be sought with viral load testing for HIV.
 
Acknowledgments

Thank you to Donald Minnich and Dennis Clark for the preparation and photography of the microbiology specimens.



More on Pharyngitis, Bacterial

Overview: Pharyngitis, Bacterial
Differential Diagnoses & Workup: Pharyngitis, Bacterial
Treatment & Medication: Pharyngitis, Bacterial
Follow-up: Pharyngitis, Bacterial
Multimedia: Pharyngitis, Bacterial
References
[ CLOSE WINDOW ]

References

  1. Spellerberg B, Brandt C. Streptococcus. In: Manual of Clinical Microbiology. 9th edition. 2007:412-29.

  2. Guilherme L, Kalil J, Cunningham M. Molecular mimicry in the autoimmune pathogenesis of rheumatic heart disease. Autoimmunity. Feb 2006;39(1):31-9. [Medline].

  3. Dale JB. Current status of group A streptococcal vaccine development. Adv Exp Med Biol. 2008;609:53-63. [Medline].

  4. Stollerman GH, Dale JB. The importance of the group a streptococcus capsule in the pathogenesis of human infections: a historical perspective. Clin Infect Dis. Apr 1 2008;46(7):1038-45. [Medline].

  5. Sriskandan S, Faulkner L, Hopkins P. Streptococcus pyogenes: Insight into the function of the streptococcal superantigens. Int J Biochem Cell Biol. 2007;39(1):12-9. [Medline].

  6. Musher DM. How contagious are common respiratory tract infections?. N Engl J Med. Mar 27 2003;348(13):1256-66. [Medline].

  7. Brook I, Gober AE. Persistence of group A beta-hemolytic streptococci in toothbrushes and removable orthodontic appliances following treatment of pharyngotonsillitis. Arch Otolaryngol Head Neck Surg. Sep 1998;124(9):993-5. [Medline].

  8. Roos K, Lind L, Holm SE. Beta-haemolytic streptococci group A in a cat, as a possible source of repeated tonsillitis in a family. Lancet. Nov 5 1988;2(8619):1072. [Medline].

  9. Wilson KS, Maroney SA, Gander RM. The family pet as an unlikely source of group A beta-hemolytic streptococcal infection in humans. Pediatr Infect Dis J. May 1995;14(5):372-5. [Medline].

  10. Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. Natl Health Stat Report. Aug 6 2008;1-29. [Medline].

  11. Carapetis JR, Steer AC, Mulholland EK, Weber M. The global burden of group A streptococcal diseases. Lancet Infect Dis. Nov 2005;5(11):685-94. [Medline].

  12. Pfoh E, Wessels MR, Goldmann D, Lee GM. Burden and economic cost of group A streptococcal pharyngitis. Pediatrics. Feb 2008;121(2):229-34. [Medline].

  13. Bisno AL, Gerber MA, Gwaltney JM Jr, Kaplan EL, Schwartz RH. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Infectious Diseases Society of America. Clin Infect Dis. Jul 15 2002;35(2):113-25. [Medline].

  14. Centor RM, Allison JJ, Cohen SJ. Pharyngitis management: defining the controversy. J Gen Intern Med. Jan 2007;22(1):127-30. [Medline].

  15. Shah M, Centor RM, Jennings M. Severe acute pharyngitis caused by group C streptococcus. J Gen Intern Med. Feb 2007;22(2):272-4. [Medline].

  16. Zaoutis T, Attia M, Gross R, Klein J. The role of group C and group G streptococci in acute pharyngitis in children. Clin Microbiol Infect. Jan 2004;10(1):37-40. [Medline].

  17. American Academy of Pediatrics. Arcanobacterium haemolyticum Infections. In: Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatrics. 27th ed. 2006:217-8.

  18. Holder NA. Gonococcal infections. Pediatr Rev. Jul 2008;29(7):228-34. [Medline].

  19. Papp JR, Ahrens K, Phillips C, Kent CK, Philip S, Klausner JD. The use and performance of oral-throat rinses to detect pharyngeal Neisseria gonorrhoeae and Chlamydia trachomatis infections. Diagn Microbiol Infect Dis. Nov 2007;59(3):259-64. [Medline].

  20. Centers for Disease Control and Prevention. Press Release. First-line Oral Gonorrhea Treatment Available Again in United States. April 25, 2008.

  21. Esposito S, Blasi F, Bosis S, et al. Aetiology of acute pharyngitis: the role of atypical bacteria. J Med Microbiol. Jul 2004;53:645-51. [Medline].

  22. Sendi P, Graber P, Lepere F, Schiller P, Zimmerli W. Mycoplasma pneumoniae infection complicated by severe mucocutaneous lesions. Lancet Infect Dis. Apr 2008;8(4):268. [Medline].

  23. Arbaji A, Kharabsheh S, Al-Azab S, et al. A 12-case outbreak of pharyngeal plague following the consumption of camel meat, in north-eastern Jordan. Ann Trop Med Parasitol. Dec 2005;99(8):789-93. [Medline].

  24. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].

  25. [Best Evidence] Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics. Feb 2009;123(2):437-44. [Medline].

  26. Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev. Jul 2004;17(3):571-80, table of contents. [Medline].

  27. Salkind AR, Wright JM. Economic Burden of Adult Pharyngitis: The Payer's Perspective. Value Health. Dec 17 2007;[Medline].

  28. [Best Evidence] Altamimi S, Khalil A, Khalaiwi KA, Milner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. Jan 21 2009;CD004872. [Medline].

  29. Pichichero ME, Casey JR. Bacterial eradication rates with shortened courses of 2nd- and 3rd-generation cephalosporins versus 10 days of penicillin for treatment of group A streptococcal tonsillopharyngitis in adults. Diagn Microbiol Infect Dis. Oct 2007;59(2):127-30. [Medline].

  30. [Best Evidence] 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. Jun 2008;93(6):474-8. [Medline].

  31. 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. Sep 2006;25(9):761-7. [Medline].

  32. Chan DS, Demers DM, Bass JW. Antimicrobial liquid formulations: a blind taste comparison of three brands of penicillin VK and three brands of amoxicillin. Ann Pharmacother. Feb 1996;30(2):130-2. [Medline].

  33. Gruchalla RS, Pirmohamed M. Clinical practice. Antibiotic allergy. N Engl J Med. Feb 9 2006;354(6):601-9. [Medline].

  34. Richter SS, Heilmann KP, Beekmann SE, et al. Macrolide-resistant Streptococcus pyogenes in the United States, 2002-2003. Clin Infect Dis. Sep 1 2005;41(5):599-608. [Medline].

  35. Malhotra-Kumar S, Lammens C, Chapelle S, et al. Macrolide- and telithromycin-resistant Streptococcus pyogenes, Belgium, 1999-2003. Emerg Infect Dis. Jun 2005;11(6):939-42. [Medline].

  36. Kaplan EL. The group A streptococcal upper respiratory tract carrier state: an enigma. J Pediatr. Sep 1980;97(3):337-45. [Medline].

  37. Orvidas LJ, St Sauver JL, Weaver AL. Efficacy of tonsillectomy in treatment of recurrent group A beta-hemolytic streptococcal pharyngitis. Laryngoscope. Nov 2006;116(11):1946-50. [Medline].

  38. Catanzaro FJ, Stetson CA, Morris AJ, et al. The role of the streptococcus in the pathogenesis of rheumatic fever. Am J Med. Dec 1954;17(6):749-56. [Medline].

  39. Steer AC, Danchin MH, Carapetis JR. Group A streptococcal infections in children. J Paediatr Child Health. Apr 2007;43(4):203-13. [Medline].

  40. Dagnelie CF, van der Graaf Y, De Melker RA. Do patients with sore throat benefit from penicillin? A randomized double-blind placebo-controlled clinical trial with penicillin V in general practice. Br J Gen Pract. Oct 1996;46(411):589-93. [Medline].

  41. Kassutto S, Rosenberg ES. Primary HIV type 1 infection. Clin Infect Dis. May 15 2004;38(10):1447-53. [Medline].

  42. American Academy of Pediatrics. Diphtheria. In: Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatrics. 27th ed. 2006:277-81.

  43. Bisno AL, Peter GS, Kaplan EL. Diagnosis of strep throat in adults: are clinical criteria really good enough?. Clin Infect Dis. Jul 15 2002;35(2):126-9. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

bacterial pharyngitis, tonsillopharyngitis, acute tonsillitis, sore throat, group A Streptococcus, GAS, streptococcal pharyngitis, Streptococcus pyogenes, S pyogenes, acute pharyngitis, upper respiratory tract infections, streptococcal fever, rheumatic fever, rheumatic heart disease, acute rheumatic fever, scarlet fever, acute glomerulonephritis, poststreptococcal glomerulonephritis, Yersinia enterocolitica, Y enterocolitica, Neisseria gonorrhoeae, N gonorrhoeae, Mycoplasma pneumoniae, M pneumoniae, Corynebacterium diphtheriae, C diphtheriae, Chlamydia pneumoniae, C pneumoniae, Arcanobacterium haemolyticum, A haemolyticum, Corynebacterium diphtheriae, respiratory diphtheria, non-group A Streptococcus, non-GAS infection, GABHS

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Eric S Halsey, MD, Chief, Department of Infectious Diseases, Wright-Patterson Air Force Base; Assistant Professor of Medicine, Uniformed Services University of the Health Sciences; Assistant Professor of Medicine, Wright State University
Eric S Halsey, MD is a member of the following medical societies: American College of Physicians, Armed Forces Infectious Diseases Society, HIV Medicine Association of America, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Kenneth C Earhart, MD, Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3
Kenneth C Earhart, MD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gordon L Woods, MD, Consulting Staff, Department of Internal Medicine, University Medical Center
Gordon L Woods, MD is a member of the following medical societies: Society of General Internal Medicine
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.