eMedicine Specialties > Infectious Diseases > HEENT Infections
Pharyngitis, Bacterial: Treatment & Medication
Updated: May 19, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Overzealous prescription of antibiotics for pharyngitis has been estimated to cost health payers $1.2 billion annually.27 Therefore, treatment of GABHS pharyngitis should be initiated only after confirmation with a RADT or throat culture.13 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.28 Antibiotic therapy does not decrease the likelihood of poststreptococcal glomerulonephritis.
Oral penicillin V remains the preferred antibiotic to treat GABHS pharyngitis.13 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.13,29 Recent reports have supported the use of once-daily amoxicillin and verified its noninferiority to twice-daily penicillin30 or twice-daily amoxicillin.31
- Palatability: Some young children find oral penicillin unpalatable. Taste tests and many doctors’ experiences have shown amoxicillin to be much better tolerated.32 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.33 Macrolides such as azithromycin and erythromycin may be used, although resistance has been reported in the United States34 and internationally.35
- 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.36 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.13 Benzathine penicillin with or without rifampin may be given when noncompliance is suspected to have been responsible for previous failures.
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.
Consultations
- An otolaryngologist should be consulted for local suppurative complications such as peritonsillar abscess and mastoiditis. Tonsillectomy may be considered in recurrent GABHS infection.37
- 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.
Diet
Allow a regular diet as tolerated in patients with bacterial pharyngitis. Warm liquids may provide symptomatic relief.
Activity
Encourage rest during the acute illness.
Medication
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.
Antibiotics
Oral penicillin is currently the drug of choice for GABHS pharyngitis.13 Amoxicillin remains a reliable alternative and offers advantages in terms of easier dosing and increased palatability.
Tetracyclines and trimethoprim/sulfamethoxazole should not be used to treat GABHS pharyngitis owing to higher rates of resistance.
Penicillin G benzathine (Bicillin L-A, Permapen)
Interferes with synthesis of cell wall by binding to penicillin-binding proteins. Penicillin is the drug of choice to treat GABHS pharyngitis, as recommended by expert committees of the American Heart Association, American Academy of Pediatrics, and the Infectious Disease Society of America, because of proven efficacy, safety, narrow spectrum, and low cost. Preferred for patients unlikely to complete a full 10-d PO course. S pyogenes remains universally sensitive to penicillin.
Adult
1.2 million U IM once
Pediatric
<27 kg: 600,000 U IM once
>27 kg: Administer as in adults
Probenecid can increase penicillin effectiveness by decreasing clearance
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in impaired renal function
Penicillin VK (Beepen VK)
Treatment of choice for GAS pharyngitis, as recommended by expert committees of the American Heart Association, American Academy of Pediatrics, and the Infectious Disease Society of America, because of its proven efficacy, safety, narrow spectrum, and low cost. Inhibits biosynthesis of cell wall by binding to penicillin-binding proteins. Bactericidal against sensitive organisms when adequate concentrations are reached and most effective during stage of active multiplication. Inadequate concentrations may be ineffective. GABHS remains uniformly susceptible in vitro.
Adult
250 mg PO tid/qid or 500 mg PO bid for 10 d
Pediatric
Children: 250 mg PO bid/tid for 10 d
Adolescents: 250 mg PO tid/qid for 10 d or 500 mg PO bid for 10 d
Probenecid may increase effectiveness by decreasing clearance
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Amoxicillin (Amoxil, Biomox, Trimox)
Interferes with synthesis of cell wall mucopeptides by binding to penicillin-binding proteins. Often used in place of oral penicillin VK in young children. Efficacy equal to penicillin, and often chosen because of the unpalatability of the penicillin susp.
Adult
500 mg PO bid for 10 d; recent studies have shown that once-daily dosing has equal efficacy; forthcoming guidelines may include this as an option
Pediatric
<40kg, 375mg PO bid for 10 d
>40kg, 500mg PO bid for 10 d; recent studies have shown that once daily dosing has equal efficacy; forthcoming guidelines may include this as an option
Reduces efficacy of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may enhance risk of candidiasis; patients with infectious mononucleosis may develop a rash if given this antibiotic
Azithromycin (Zithromax)
Inhibits RNA-dependent protein synthesis at the 50s ribosome. Can be given as a single daily dose, is better tolerated than erythromycin in patients who are allergic to penicillin, and is effective in a 5-d course. However, much more expensive and should be avoided as first-line therapy in patients with streptococcal pharyngitis. Sporadic resistance has been reported.
Adult
Day 1: 500 mg PO
Days 2-5: 250 mg PO qd
Pediatric
<6 months: Not established
>6 months
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in patients who are hospitalized, elderly, or debilitated
Erythromycin (E.E.S., E-Mycin, Ery-Tab, Erythrocin)
Inhibits RNA-dependent protein synthesis at the 50s ribosome. An option in those with severe allergic reactions to beta-lactam antibiotics. Sporadic resistance has been reported.
Adult
333 mg PO tid for 10 d or 500 mg PO qid for 10 d
Pediatric
20-40 mg/kg/d PO in 2-4 divided doses for 10 d
Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis
Documented hypersensitivity; hepatic impairment
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common; discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Clindamycin (Cleocin)
Belongs to the lincosamide class of antibiotics. Binds to the 50s ribosome and prevents bacterial protein synthesis. Is an option for symptomatic patients with multiple, recurrent episodes of pharyngitis proven by culture or rapid antigen testing.
Adult
600 mg/d PO divided bid/qid for 10 d
Pediatric
20-30 mg/kg/d PO tid for 10 d
Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
Cephalexin (Keflex)
First-generation cephalosporin that arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Oral cephalosporins are highly effective for streptococcal pharyngitis, and several studies have found them to have slightly higher eradication rates than those of penicillin. Second-line agents in the treatment of patients with GABHS pharyngitis.
Adult
500 mg PO bid for 10 d
Pediatric
25-50 mg/kg/d PO divided bid for 10 d
May increase level of metformin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
More on Pharyngitis, Bacterial |
| Overview: Pharyngitis, Bacterial |
| Differential Diagnoses & Workup: Pharyngitis, Bacterial |
 Treatment & Medication: Pharyngitis, Bacterial |
| Follow-up: Pharyngitis, Bacterial |
| Multimedia: Pharyngitis, Bacterial |
| References |
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References
Spellerberg B, Brandt C. Streptococcus. In: Manual of Clinical Microbiology. 9th edition. 2007:412-29.
Guilherme L, Kalil J, Cunningham M. Molecular mimicry in the autoimmune pathogenesis of rheumatic heart disease. Autoimmunity. Feb 2006;39(1):31-9. [Medline].
Dale JB. Current status of group A streptococcal vaccine development. Adv Exp Med Biol. 2008;609:53-63. [Medline].
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].
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].
Musher DM. How contagious are common respiratory tract infections?. N Engl J Med. Mar 27 2003;348(13):1256-66. [Medline].
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].
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].
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].
Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. Natl Health Stat Report. Aug 6 2008;1-29. [Medline].
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].
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].
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].
Centor RM, Allison JJ, Cohen SJ. Pharyngitis management: defining the controversy. J Gen Intern Med. Jan 2007;22(1):127-30. [Medline].
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].
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].
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.
Holder NA. Gonococcal infections. Pediatr Rev. Jul 2008;29(7):228-34. [Medline].
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].
Centers for Disease Control and Prevention. Press Release. First-line Oral Gonorrhea Treatment Available Again in United States. April 25, 2008.
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].
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].
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].
Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].
[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].
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].
Salkind AR, Wright JM. Economic Burden of Adult Pharyngitis: The Payer's Perspective. Value Health. Dec 17 2007;[Medline].
[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].
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].
[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].
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].
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].
Gruchalla RS, Pirmohamed M. Clinical practice. Antibiotic allergy. N Engl J Med. Feb 9 2006;354(6):601-9. [Medline].
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].
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].
Kaplan EL. The group A streptococcal upper respiratory tract carrier state: an enigma. J Pediatr. Sep 1980;97(3):337-45. [Medline].
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].
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].
Steer AC, Danchin MH, Carapetis JR. Group A streptococcal infections in children. J Paediatr Child Health. Apr 2007;43(4):203-13. [Medline].
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].
Kassutto S, Rosenberg ES. Primary HIV type 1 infection. Clin Infect Dis. May 15 2004;38(10):1447-53. [Medline].
American Academy of Pediatrics. Diphtheria. In: Red Book: Report of the Committee on Infectious Diseases. American Academy of Pediatrics. 27th ed. 2006:277-81.
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].
Further Reading
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
