eMedicine Specialties > Infectious Diseases > HEENT Infections

Pharyngitis, Viral: Follow-up

Author: KoKo Aung, MD, MPH, FACP, Associate Professor, Department of Medicine, University of Texas Health Science Center; Adjunct Assistant Professor of Public Health, University of Texas School of Public Health
Coauthor(s): Ambrish Ojha, MD, Staff Physician, Department of Internal Medicine, Texas Tech University Health Sciences Center; Carson Lo, MD, Staff Physician, Department of Medicine, Memorial Hermann Southwest Hospital
Contributor Information and Disclosures

Updated: Jan 20, 2009

Follow-up

Deterrence/Prevention

• Washing hands frequently, using disposable tissues, and limiting human contact are important preventive measures for the common cold syndrome and other viral pharyngitis. No consistent benefit was demonstrated in preventing a common cold with large doses of vitamin C.
• Live adenovirus vaccines have been successfully used in military populations but are not available for civilian use.
• Administration of influenza vaccine to high-risk individuals and those who want to prevent influenza is the major preventive measure. Amantadine may be used to prevent influenza A during outbreaks.

Complications

• The complication rate of viral pharyngitis associated with a common cold is quite low. Purulent bacterial otitis media and sinusitis may occur.
• Infectious mononucleosis may be complicated by tonsillar and peritonsillar abscess, necrotic epiglottitis, airway obstruction, hepatic dysfunction, splenic rupture, hypersplenism, encephalitis, pneumonitis, pericarditis, and hematologic disorders.
• Herpetic pharyngitis may lead to necrotizing tonsillitis, epiglottitis, and recurrent disease.
• Influenza may be complicated by secondary bacterial pneumonia. Pneumococcal pneumonia is most common. Staphylococcal pneumonia is most serious.
• RSV infection, particularly in infants, elderly persons, and patients with underlying COPD, may be complicated by pneumonia and respiratory failure.
• Complications of HIV infection are beyond the scope of this article. For more information, see the eMedicine article HIV Disease.

Prognosis

• The prognosis of a patient with a common cold is excellent. Most adults recover in less than a week, and most children in less than 2 weeks.
• In patients with infectious mononucleosis, fever disappears in approximately 10 days. Lymphadenopathy and splenomegaly disappear in approximately 4 weeks. Debility sometimes remains for approximately 2-3 months, and the condition is occasionally fatal because of splenic rupture, hypersplenism, or encephalitis.
• The duration of uncomplicated influenza is 1-7 days. Prognosis is excellent. Most fatalities are due to secondary bacterial pneumonia.
• Enteroviral pharyngitis is usually benign and self-limited.

Patient Education

• Patient education should emphasize the natural course of viral infection and that it takes several days to feel better. Patients must understand that antibiotics are not needed for sore throats of viral origin. Risk of allergic reactions, fungal superinfection, and bacterial resistance should be discussed.
• Patients should be reassured that certain measures, including pain relievers, throat sprays or lozenges, and gargling with warm salt water, improve symptoms without antibiotics. It is often challenging to reassure that antibiotic therapy is unnecessary.²
• Fever persisting for more than 5 days, extreme throat pain causing dysphagia, inability to open the mouth wide, or fainting spells when standing should prompt a visit to a doctor.
• For excellent patient education resources, visit eMedicine's Cold and Flu Center, Bacterial and Viral Infections Center and Ear, Nose, and Throat Center. Also, see eMedicine's patient education articles Colds, Sore Throat, Mononucleosis, and Tonsillitis.

Miscellaneous

Medicolegal Pitfalls

• The major role of the clinician in evaluating viral pharyngitis is to distinguish pharyngitis caused by different viruses from that caused by group A beta hemolytic streptococcus (GABHS) because the latter may lead to serious sequelae such as rheumatic fever and poststreptococcal glomerulonephritis.
• Differentiating streptococcal from viral pharyngitis is important because of the response of streptococcal infection to penicillin therapy and the ineffectiveness of antibiotic therapy in the viral infections.
• Absence of fever or the presence of clinical features, such as conjunctivitis, cough, hoarseness, coryza, anterior stomatitis, discrete ulcerative lesions, viral exanthem, and diarrhea, strongly suggests a viral rather than streptococcal etiology.
• A systematic review that examined the precision and accuracy of the clinical examination in diagnosing streptococcal pharyngitis found that the most useful findings for evaluating the likelihood of streptococcal pharyngitis included the presence of tonsillar exudate, pharyngeal exudate, or exposure to strep throat infection in the previous 2 weeks (positive likelihood ratios, 3.4, 2.1, and 1.9, respectively) and the absence of tender anterior cervical nodes, tonsillar enlargement, or exudate (negative likelihood ratios, 0.60, 0.63, and 0.74, respectively).⁸
• Although a throat swab is commonly recommended to confirm or exclude streptococcal pharyngitis, the test's sensitivity and specificity are somewhat low (26-30% and 73-80%, respectively) compared to the criterion standard of a rise in antistreptolysin O titer. The high asymptomatic carrier rate of GABHS is probably responsible for the low predictive value of throat swabs. The rapid antigen detection test (RADT) is even less sensitive than throat cultures.
• The rationale behind treating people with pharyngitis with antibiotics is to reduce the symptoms and the likelihood of developing complications if the condition is streptococcal in etiology. Conversely, prescribing antibiotics to everyone has some disadvantages, including, but not limited to, adverse effects of antibiotics, direct costs of antibiotics, and the impact on bacterial resistance.
• Unnecessary antibiotic therapy for viral pharyngitis can lead to medicalization of a self-limiting illness, resulting in increasing reattendance for future episodes of this condition.⁹
• Practice guidelines from the Infectious Disease Society of America (IDSA) and Standing Medical Advisory Committee of United Kingdom recommend prescribing antibiotics in patients in whom GABHS has been identified. Unfortunately, no satisfactory diagnostic test is available that can identify such patients in a timely manner.
• Earlier scoring systems attempting to identify the streptococcal infection among patients presenting with pharyngitis correlated poorly with microbiological data. In Canada, a sore throat score based on clinical symptoms and signs for identification of streptococcal infection has been developed and validated in children and adults.¹⁰ An explicit clinical score approach to the management of patients with pharyngitis could substantially reduce unnecessary prescribing of antibiotics for viral pharyngitis.
• A multicriteria decision analysis using the Analytic Hierarchy Process (AHP) was recently conducted to help clinicians better understand the differences between the conflicting guidelines on initial approach in a patient with pharyngitis.¹¹ The AHP is one of several multicriteria decision-analysis methods designed to help people make better decisions in complex situations that involve tradeoffs between the advantages and disadvantages of several alternatives. The results of the AHP analysis suggest that decisions about management of adults with sore throat should incorporate both clinical estimates of the likelihood of a group A streptococcal infection and the priorities assigned to pertinent decision criteria by those affected by the decision. Additional research, however, is needed to establish the criteria to define quality management of adults who present with pharyngitis.

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