Bacterial Pharyngitis Treatment & Management

  • Author: Eric S Halsey, MD; Chief Editor: Burke A Cunha, MD   more...
 
Updated: Jan 11, 2012
 

Medical Care

Overzealous prescription of antibiotics for pharyngitis has been estimated to cost health payers $1.2 billion annually.[29] Therefore, treatment of GABHS pharyngitis should be initiated only after confirmation with a RADT or throat culture.[14] Alternatively, treatment in high-risk patients may be started before throat culture results are available, but antibiotics should be stopped if the culture returns negative results. Even though most cases of GABHS pharyngitis resolve after 3-4 days without treatment, antibiotics decrease the likelihood of local suppurative complications and acute rheumatic fever. Oral antibiotics should be administered for 10 days, although many recent studies show similar efficacy with shorter courses.[30] Antibiotic therapy does not decrease the likelihood of poststreptococcal glomerulonephritis.

Oral penicillin V remains the preferred antibiotic to treat GABHS pharyngitis.[14] In vitro, no isolate of GABHS has ever been resistant to penicillin. Other reasons favoring oral penicillin include its narrow spectrum, low cost, infrequent adverse effects, and proven track record. Nevertheless, GABHS is sensitive to many other antibiotics, thereby allowing flexibility based on numerous factors.

The following circumstances dictate that a choice other than penicillin V should be used:

  • Compliance: Oral penicillin requires multiple daily doses and a 10-day course. In patients unlikely to adhere to this regimen, one dose of intramuscular benzathine penicillin provides a depot that releases medication over the course. Azithromycin, cefdinir, and cefpodoxime may all be given in 5-day courses, although none of these medications is yet considered a first-line agent.[14, 31, 32] Recent reports have supported the use of once-daily amoxicillin and verified its noninferiority to twice-daily penicillin[33] or twice-daily amoxicillin.[34]
  • Palatability: Some young children find oral penicillin unpalatable. Taste tests and many doctors’ experiences have shown amoxicillin to be much better tolerated.[35] Amoxicillin’s similar spectrum and low cost make it a reasonable substitute.
  • Allergy: In patients with an immunoglobulin E (IgE)–mediated penicillin allergy, antibiotics that contain a beta-lactam ring (cephalosporins, amoxicillin) should be used with extreme caution. Although cross-reactivity between penicillin and cephalosporins is probably less than 10%, the risk of anaphylaxis justifies the consideration of other viable agents.[36] Macrolides such as azithromycin and erythromycin may be used, although resistance has been reported in the United States[37] and internationally.[38]
  • Recurrence: Test of cure is not indicated when pharyngitis symptoms have resolved following treatment. In patients with recurrent symptoms, retreatment with an initial first-line agent (oral penicillin, benzathine penicillin, erythromycin, or a first-generation cephalosporin) is reasonable. Worth noting is the difficulty in differentiating between viral pharyngitis with GABHS carriage and actual GABHS pharyngitis. This becomes even more of an issue in patients with multiple recurrences. Between 5% and 15% of children are asymptomatic carriers during seasons when GABHS pharyngitis is most prevalent.[39] A positive test result during a time of wellness may indicate GABHS carriage. When multiple recurrences are believed to be due to GABHS infection, clindamycin or amoxicillin/clavulanic acid is indicated.[14] Benzathine penicillin with or without rifampin may be given when noncompliance is suspected to have been responsible for previous failures.
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Surgical Care

In rare cases, pharyngitis spreads to adjacent structures and forms abscesses. In these cases, a drainage procedure performed by an interventional radiologist or otolaryngologist should be considered.

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Consultations

  • An otolaryngologist should be consulted for local suppurative complications such as peritonsillar abscess and mastoiditis. Tonsillectomy may be considered in recurrent GABHS infection.[40]
  • An infectious diseases expert may be consulted for patients with immunocompromising conditions or when an agent other than GABHS (eg, HIV) is suspected or confirmed.
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Diet

Allow a regular diet as tolerated in patients with bacterial pharyngitis. Warm liquids may provide symptomatic relief.

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Activity

Encourage rest during the acute illness.

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Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Eric S Halsey, MD  Head, Virology Department, Naval Medical Research Center Detachment-Peru (NMRCD-Peru); Assistant Professor of Medicine, Uniformed Services University of the Health Sciences

Eric S Halsey, MD is a member of the following medical societies: Armed Forces Infectious Diseases Society, HIV Medicine Association of America, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

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.

Additional Contributors

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

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Picture of Streptococcus pyogenes at 100 X magnification.
Rapid antigen detection test for group A beta-hemolytic streptococci.
Posterior pharynx with petechiae and exudates in a 12-year-old girl. Both the rapid antigen detection test and throat culture were positive for group A beta-hemolytic Streptococcus.
 
 
 
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