Pharyngitis in Emergency Medicine Follow-up

  • Author: John R Acerra, MD; Chief Editor: Pamela L Dyne, MD   more...
 
Updated: May 6, 2010
 

Further Inpatient Care

  • Inpatient care usually is not indicated except in cases such as epiglottitis, severe dehydration, deep-space infection, other airway compromise, or diphtheria.
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Further Outpatient Care

  • Follow-up for GAS pharyngitis
    • A standardized protocol needs to be established at each institution or ED to ensure follow-up for patients with pending throat cultures. This is particularly challenging with unreliable patients and with a shift-dependent ED practice.
    • Whether or not they are given antibiotics, patients diagnosed with pharyngitis should follow up if symptoms do not improve within 72 hours.
    • Routine posttreatment throat cultures are unnecessary and may remain positive for several weeks.[1]
    • A follow-up culture should be taken if history or evidence of rheumatic fever or if symptoms are consistent with a relapse.[21]
  • Patients with infectious mononucleosis should be instructed to follow up with their physician in 1 week. These patients should also be advised to avoid contact sports.[9]
  • Viral pharyngitis generally requires no specific follow-up unless immunosuppression is suspected or symptoms worsen.
  • Patients with suspected malignancy should be referred to an otolaryngologist for follow-up.
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Transfer

  • Transfer usually is not necessary for simple acute pharyngitis.
  • The airway should be evaluated and endotracheal intubation should be performed prior to transfer if a high probability of compromise exists during transfer.
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Deterrence/Prevention

  • Throat cultures should be obtained on close contacts of patients with a history of a nonsuppurative complication (acute rheumatic fever) of a streptococcal infection or if recurrent outbreaks of GAS pharyngitis occur.[5]
  • Diphtheria immunization is highly effective and recommended for nonimmunized patients to reduce potential morbidity and mortality of the disease.
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Complications

  • General complications of pharyngitis (mainly seen in cases of bacterial pharyngitis) include sinusitis, otitis media, epiglottitis, mastoiditis, and pneumonia.
    • Suppurative complications of bacterial pharyngitis result from spread of infection from pharyngeal mucosa via hematogenous, lymphatic, or direct extension (more common with GAS); peritonsillar abscess; retropharyngeal abscess; or suppurative cervical lymphadenitis. It is unclear if antibiotic therapy can prevent these complications as abscess isolates are often polymicrobial. Many experts believe these are actually independent entities and not related to GAS pharyngitis.
  • In addition to the above general complications, nonsuppurative complications (3% incidence) specific to GAS infection include acute rheumatic fever (3-5 wk postinfection), poststreptococcal glomerulonephritis, and toxic shock syndrome.
  • Complications of infectious mononucleosis include splenic rupture (contact sports should be avoided for 6 wk), hepatitis, Guillain-Barré syndrome, encephalitis, hemolytic anemia, agranulocytosis, myocarditis, B-cell lymphoma, and nasopharyngeal carcinoma. Use of penicillin in cases of infectious mononucleosis results in near 100% incidence of rash.[9]
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Prognosis

  • Most cases of pharyngitis resolve spontaneously within 10 days, but it is important for the clinician to be aware of potential complications listed above.
  • Treatment failures are frequent and are attributed mainly to poor compliance, antibiotic resistance, untreated close contacts, carrier states, and antibiotic-related or copathogenic suppression of host immunity and necessary flora.[4] Of note, GAS resistance to penicillin is NOT thought to be a reason for treatment failures with penicillin.
  • Patients should expect improvement in symptoms in penicillin-sensitive streptococcal pharyngitis within 24 hours of initiation of treatment. Contagious and often the febrile periods also are reduced to 1 day.
  • With erythromycin therapy, patients should expect improvement in 72 hours. The incidence of streptococcal resistance to erythromycin may exceed 30%.[7] Therefore, patients on erythromycin therapy should be more closely monitored for treatment failure.
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Patient Education

  • Patients must be instructed to complete the full course of antibiotic therapy, as improvement may occur rapidly.
  • Patients should be instructed to follow up when indicated (see Further Outpatient Care).
  • Patients with infectious mononucleosis should be instructed to avoid contact sports for a period of 6 weeks because of the possibility of splenic rupture.
  • Patients should be educated about symptomatic treatment of pharyngitis.
    • Ibuprofen or acetaminophen is recommended for analgesia.
    • Saltwater gargle, warm liquids, and rest may be helpful in relieving symptoms.
  • For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Sore Throat and Mononucleosis.
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Contributor Information and Disclosures
Author

John R Acerra, MD  Assistant Professor, Department of Emergency Medicine, Albert Einstein College of Medicine; Associate Director, International Emergency Medicine Fellowship, North Shore - LIJ Health System

John R Acerra, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Jerry Balentine, DO  Professor of Emergency Medicine, New York College of Osteopathic Medicine; Executive Vice President, Chief Medical Officer, Attending Physician in Department of Emergency Medicine, St. Barnabas Hospital

Jerry Balentine, DO is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American College of Physician Executives, American Osteopathic Association, and New York Academy of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Mark W Fourre, MD  Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD  Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center

Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

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  4. Pichichero ME, Casey JR. Systematic review of factors contributing to penicillin treatment failure in Streptococcus pyogenes pharyngitis. Otolaryngol Head Neck Surg. Dec 2007;137(6):851-857. [Medline].

  5. [Guideline] Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. Mar 24 2009;119(11):1541-51. [Medline].

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  10. Lemierre's syndrome, reemergence of a forgotten disease: a case report. Cases J. Mar 10 2009;2:6397. [Medline].

  11. [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].

  12. Ayanruoh S, Waseem M, Quee F, Humphrey A, Reynolds T. Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department. Pediatr Emerg Care. Nov 2009;25(11):748-50. [Medline].

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  20. Pichichero M, Casey J. Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis. Eur J Clin Microbiol Infect Dis. Jun 2006;25(6):354-64. [Medline].

  21. Brook I. Overcoming penicillin failures in the treatment of Group A streptococcal pharyngo-tonsillitis. Int J Pediatr Otorhinolaryngol. Oct 2007;71(10):1501-8. [Medline].

  22. Depdham D, Rao S, Hitchcock K. Should you treat carriers of pharyngeal group A strep?. J Fam Pract. 2008;57.

  23. [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].

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Streptococcus pyogenes at 100X 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 streptococci.
 
 
 
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