eMedicine Specialties > Infectious Diseases > HEENT Infections
Pharyngitis, Viral: Treatment & Medication
Updated: Jan 20, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
Treatment strategies for patients with acute pharyngitis are based on epidemiologic factors, signs and symptoms, and results of laboratory tests.1 Rest, oral fluids, and salt-water gargling (for soothing effect) are the main supportive measures in patients with viral pharyngitis.2
Analgesics and antipyretics may be used for relief of pain or pyrexia. Acetaminophen is the drug of choice. Traditionally, aspirin has been used, but it may increase viral shedding. Aspirin should not be used in children or adolescents, especially with influenza, because of its association with Reye syndrome. One study proved that ibuprofen was superior to acetaminophen for symptomatic relief in children aged 6-12 years. A double-blind randomized study involving adult patients from 27 study centers in Latin America found that 5 days of treatment with celecoxib 200 mg once daily is as effective as diclofenac 75 mg twice daily in the symptomatic treatment of viral pharyngitis.3
Anesthetic gargles and lozenges, such as benzocaine, may be used for symptomatic relief. Hospitalization for intravenous hydration may be necessary when odynophagia is intense.
Antibiotics do not hasten recovery or reduce the frequency of bacterial complications. The risks of prescribing antibiotics in patients with viral pharyngitis include the common side effects of antibiotics (diarrhea, rashes, candidiasis, unplanned pregnancy secondary to oral-contraceptive failure) and the rare occurrence of anaphylaxis.4
Specific treatment of viral infections is available for only a few viruses.
- Influenza
- Beginning treatment with one of the adamantanes (amantadine or rimantadine) within 48 hours of the onset of illness decreases the duration of symptoms in influenza A infection.5 However, both agents lack activity against influenza B infection, which is usually mild.
- Adamantanes can be used in cases of presumed influenzal pharyngitis occurring during a known influenza type A epidemic. The major advantage of rimantadine is a low-risk risk of central nervous system effects, such as lightheadedness, difficulty concentrating, nervousness, and insomnia, which can be a significant problem with amantadine, particularly in elderly patients.
- Ribavirin has helped patients severely ill with influenza A or B infections.
- Newer neuraminidase inhibitors (inhaled zanamivir, oral oseltamivir) started within 30 hours of the onset of influenza can shorten the duration of symptoms and, possibly, decrease the rate of complications.6
- Drug resistance of different strains of influenza A and B complicates antiviral therapy. Of the 50 influenza A (H1N1) viruses identified in the United States from October 1, 2008, through December 13, 2008, and tested by the CDC, 49 (98%) were resistant to oseltamivir. All influenza A (H1N1) viruses tested in fall 2008 were susceptible to the adamantanes (amantadine and rimantadine). All influenza A (H3N2) and influenza B viruses tested in fall 2008 were susceptible to oseltamivir, and all influenza A (H1N1) and A (H3N2) and influenza B viruses tested during this period were susceptible to zanamivir. Resistance to the adamantanes among influenza A (H3N2) viruses remained high at the time of this revision (December 25, 2008), with 100% of viruses tested found to be adamantane-resistant.7
- EBV Infectious mononucleosis
- Specific antiviral therapy with acyclovir, ganciclovir, and interferon alfa reduces viral shedding but does not improve clinical outcome.
- Corticosteroids may improve the symptoms, but they are generally not recommended because infectious mononucleosis is usually benign and self-limited.
- However, corticosteroids are indicated if the patient has massive tonsillar hypertrophy that threatens to obstruct the airway.
- Herpes simplex virus
- In an immunocompetent host, oral acyclovir, famciclovir, and valacyclovir decrease the duration of symptoms and viral shedding.
- In an immunocompromised host, these drugs decrease pain and viral shedding and accelerate healing of lesions. These drugs are helpful in severely afflicted patients.
- Acute retroviral syndrome
- Several unique considerations favor antiretroviral therapy during this phase of HIV infection. Treatment may limit the extent of viral dissemination throughout the body, attenuate the progress of HIV infection by lowering the plasma viral RNA set point, and limit the extent of viral genetic variability, which is responsible for drug resistance.
- Treatment may also allow salvage of a CD4 T-cell–specific immune response that may be important in the immune control of HIV infection.
Diet
Drinking large amounts of fluid is recommended. No specific dietary restrictions are needed. Soft, cold foods (eg, ice cream, popsicles) are more easily tolerated.
Activity
No restriction in activity is required.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Analgesics/antipyretics
These agents are often helpful in relieving the pain and fever associated with pharyngitis.
Acetaminophen (Tylenol)
Relieves pain by elevation of the pain threshold. Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
Adult
325-650 mg PO q4-6h prn; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: Administer as in adults
Rifampin can reduce analgesic effects; coadministration with barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in persons with chronic alcoholism following various dose levels; contained in many OTC products, and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Ibuprofen (Advil, Motrin)
Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 5-10 mg/kg/dose PO q4-6h prn; not to exceed 40 mg/kg/d
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase risk of methotrexate toxicity (animal studies only); phenytoin levels may be increased when administered concurrently
Documented hypersensitivity to ibuprofen or other NSAIDs
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Risk of GI ulceration, bleeding, and perforation, particularly in patients with active peptic ulcer disease or with a history of peptic ulcer disease; caution in CHF, hypertension, and decreased renal function (maintenance of renal perfusion highly dependent on renal prostaglandins) and hepatic function (severe hepatic reactions including jaundice and cases of fatal hepatitis have been reported); caution in anticoagulation abnormalities or during anticoagulant therapy (inhibits platelet aggregation); if signs or symptoms of meningitis develop, the possibility of aseptic meningitis related to ibuprofen should be considered; if blurred and/or diminished vision, scotomata, and/or changes in color vision develop, ibuprofen should be discontinued, and visual field and color vision testing should be performed; not recommended in breastfeeding mothers
Topical anesthetics
These agents soothe irritated or inflamed mucous membranes associated with sore throat.
Benzocaine (Trocaine, Benzocol, Cylex, Cepacol Maximum Strength)
Lozenges or gargle reduces pain associated with pharyngitis. Inhibits neuronal membrane depolarization, blocking nerve impulses.
Adult
Dissolve 1 lozenge (10 mg) in mouth q2h prn
Pediatric
<6 years: Not established
>6 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Reevaluate the patient if sore throat is severe, persists for more than 2 d, or is accompanied or followed by fever, headache, rash, nausea, or vomiting
Antiviral Agents
These agents are used specifically to treat viral infections. They are available for only a few viruses.
Amantadine (Symmetrel)
Active against influenza A virus. Has little or no activity against influenza B virus isolates. Mechanism of antiviral action is unclear. Prevents release of infectious viral nucleic acid into the host cell by interfering with the function of the transmembrane domain of the viral M2 protein. In certain cases, known to prevent virus assembly during virus replication. Treatment begun within 48 h of the onset of symptoms decreases the duration of fever and other symptoms.
Adult
200 mg/d PO qd or divided bid; split dosage schedule may reduce adverse CNS effects
>65 years: 100 mg/d PO qd or divided bid
Hemodialysis: 200 mg PO qwk
Pediatric
<1 year: Not recommended
1-9 years: 4.4-8.8 mg/kg/d PO qd or divided bid; not to exceed 150 mg/d
9-12 years: 100 mg PO bid
>12 years: Administer as in adults
Agents with anticholinergic activity potentiate anticholinergic adverse effects; concurrent administration of triamterene/ hydrochlorothiazide may increase plasma concentrations; coadministration of thioridazine has been reported to worsen tremor in elderly patients with Parkinson disease; however, it is not known if other phenothiazines produce similar response; trimethoprim/ sulfamethoxazole may impair renal clearance, resulting in higher plasma concentrations; coadministration of quinine or quinidine decreases renal clearance
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in liver disease, uncontrolled psychosis, eczematoid dermatitis, seizures, and those receiving CNS stimulant drugs; reduce dose in renal dysfunction; do not discontinue this medication abruptly
Rimantadine (Flumadine)
Inhibits viral replication of influenza A virus H1N1, H2N2, and H3N2 with little or no activity against influenza B virus. Prevents penetration of the virus into the host by inhibiting uncoating of influenza A. Does not appear to interfere with the immunogenicity of inactivated influenza A vaccine. Can be used together during an outbreak.
Adult
100 mg PO bid
CrCl <10 mL/min, severe hepatic dysfunction, and elderly nursing home patients: 100 mg PO qd
Pediatric
<10 years: Not recommended
>10 years: Administer as in adults
Acetaminophen and aspirin reduce levels when taken concurrently; cimetidine increases plasma levels when taken concomitantly
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal or hepatic impairment; should be discontinued if seizures develop
Oseltamivir (Tamiflu)
Inhibits neuraminidase, which is a glycoprotein on the surface of influenza virus that destroys an infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, decreases release of viruses from infected cells and thus viral spread. Effective to treat influenza A or B. Start within 40 h of symptom onset. Available as capsules and an oral suspension.
Adult
Acute illness: 75 mg PO bid for 5 d
Prophylaxis: 75 mg PO qd for 10 d
Pediatric
Acute illness:
<1 year: Not indicated
>1 year:
<15 kg: 30 mg PO bid for 5 d
>15-23 kg: 45 mg PO bid for 5 d
>23-40 kg: 60 mg PO bid for 5 d
>40 kg: Administer as in adults
Prophylaxis:
<1 year: Not established
>1 year:
<15 kg: 30 mg PO qd for 10 d
>15-23 kg: 45 mg PO qd for 10 d
24-40 kg: 60 mg PO qd for 10 d
>40 kg: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in renal impairment, chronic cardiac or respiratory disease, and breastfeeding; do not use in children <1 y (preclinical trials have demonstrated death in young animals, possibly related to immature blood-brain barriers); postmarketing reports (mostly from Japan) of self-injury and delirium in patients with influenza (reports primarily among children), unknown if oseltamivir directly contributes to this behavior (monitor for abnormal behavior throughout treatment period)
Acyclovir (Zovirax)
Synthetic purine nucleoside analogue with in vitro and in vivo inhibitory activity against HSV-1, HSV-2, and VSV. Inhibitory activity is highly selective because of its affinity for the enzyme thymidine kinase (TK) encoded by HSV and VZV.
Adult
Acute herpetic pharyngitis or gingivostomatitis: 200 mg PO 5 times/d or 400 mg PO tid for 10-14 d
Pediatric
<2 years: Not recommended
>2 years: 20 mg/kg/dose PO qid for 10-14 d; not to exceed 800 mg/d
Concomitant use of probenecid or zidovudine prolongs half-life and increases CNS toxicity; decreases the renal clearance of methotrexate with potential toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure (adjust dose) or when using nephrotoxic drugs; caution in breastfeeding mothers
Valacyclovir (Valtrex)
Prodrug rapidly converted to the active drug acyclovir. More expensive but has a more convenient dosing regimen than acyclovir.
Adult
500-1000 mg PO bid
Pediatric
Not established
Probenecid, zidovudine, or cimetidine coadministration prolongs half-life and increases CNS toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure and coadministration of nephrotoxic drugs; associated with onset of hemolytic uremic syndrome
Famciclovir (Famvir)
Prodrug that when biotransformed into active metabolite, penciclovir, may inhibit viral DNA synthesis/replication.
Adult
250-500 mg PO tid
Pediatric
Not recommended
Coadministration of probenecid or cimetidine may increase toxicity; coadministration increases bioavailability of digoxin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Caution in renal failure or coadministration of nephrotoxic drugs
Antiviral Agent, Inhalation Therapy
Zanamivir (Relenza)
Inhibitor of neuraminidase, which is a glycoprotein on the surface of the influenza virus that destroys the infected cell's receptor for viral hemagglutinin. By inhibiting viral neuraminidase, release of viruses from infected cells and viral spread are decreased. Effective against both influenza A and B. To be inhaled through Diskhaler oral inhalation device. Circular foil discs containing 5-mg blisters of drug are inserted into supplied inhalation device.
Adult
Treatment: 10 mg (2 inhalations, 5 mg/inhalation) inhaled PO q12h for 5 d; initiate within 2 d of symptom onset
Prophylaxis: 10 mg (2 inhalations, 5 mg/inhalation) inhaled PO qd for 10 d; initiate within 36 h of exposure
Pediatric
Treatment:
<7 years: Not established
>7 years: Administer as in adults
Prophylaxis:
<5 years: Not established
>5 years: Administer as in adults
None reported
Documented hypersensitivity, obstructive airway disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Monitor respiratory status; may cause bronchospasm; caution in breastfeeding
More on Pharyngitis, Viral |
| Overview: Pharyngitis, Viral |
| Differential Diagnoses & Workup: Pharyngitis, Viral |
 Treatment & Medication: Pharyngitis, Viral |
| Follow-up: Pharyngitis, Viral |
| References |
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References
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Further Reading
Keywords
viral pharyngitis, sore throat, acute pharyngitis, rhinoviral pharyngitis, adenoviral pharyngitis, EBV pharyngitis, HSV pharyngitis, influenzal pharyngitis, parainfluenzal pharyngitis, coronaviral pharyngitis, enteroviral pharyngitis, echoviral pharyngitis, RSV pharyngitis, CMV pharyngitis, cytomegaloviral pharyngitis, common cold, flu, influenza, pharynx, tonsils, upper respiratory tract infection, URTI, rhinovirus, adenovirus, Epstein-Barr virus, EBV, herpes simplex virus, HSV, parainfluenza virus, coronavirus, enterovirus, respiratory syncytial virus, RSV, cytomegalovirus, CMV, human immunodeficiency virus, HIV, coxsackievirus, echovirus, acute retroviral syndrome, infectious mononucleosis, IM, group A beta hemolytic streptococcus, GABHS
