eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Pharyngitis: Follow-up

Author: John R Acerra, MD, Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh; Attending Physician, The Western Pennsylvania Hospital
Contributor Information and Disclosures

Updated: Aug 10, 2009

Follow-up

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.

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.19
  • 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.

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.

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.

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

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.

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.

Miscellaneous

Medicolegal Pitfalls

  • Medical/legal issues usually are not applicable in uncomplicated pharyngitis.
  • Chronic pharyngitis should elicit a search for the possibility of malignancy, particularly in patients with predisposing factors such as age and tobacco or alcohol use.
  • Be aware of the signs of immunosuppression and perform HIV screening if clinically indicated.
  • Carefully document follow-up instructions and signs and symptoms of recurrence so that complications can be avoided.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, A Antoine Kazzi, MD, and Jeannine Wills, MD, to the development and writing of this article.



More on Pharyngitis

Overview: Pharyngitis
Differential Diagnoses & Workup: Pharyngitis
Treatment & Medication: Pharyngitis
Follow-up: Pharyngitis
Multimedia: Pharyngitis
References
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References

  1. Alcaide AL, Bisno AL. Pharyngitis and epiglotittis. Infect Dis Clin North Am. 2006;21:449-469.

  2. Twefik TL, Al Garni M. Tonsillopharyngitis: Clinical highlights. J of Otolaryngology. 2005;34.

  3. Mostov PD. Treating the immunocompetent patient who presents with an upper respiratory infection: pharyngitis, sinusitis, and bronchitis. Prim Care. Mar 2007;34(1):39-58. [Medline].

  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. 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].

  6. Centor RM, Allison JJ, Cohen SJ. Pharyngitis management: defining the controversy. J Gen Intern Med. Jan 2007;22(1):127-30. [Medline].

  7. [Guideline] 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].

  8. Wagner FP, Mathiason MA. Using centor criteria to diagnose streptococcal pharyngitis. Nurse Pract. Sep 2008;33(9):10-2. [Medline].

  9. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].

  10. [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].

  11. Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Emerg Med. Jun 2001;37(6):711-9. [Medline].

  12. Patel NN, Patel DN. Acute exudative tonsillitis. Am J Med. Jan 2009;122(1):18-20. [Medline].

  13. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Review). The Cochrane Collaboration. 2007;(1):1-41.

  14. Tasar A, Yanturali S, Topacoglu H, Ersoy G, Unverir P, Sarikaya S. Clinical efficacy of dexamethasone for acute exudative pharyngitis. J Emerg Med. Nov 2008;35(4):363-7. [Medline].

  15. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. Sep-Oct 2007;5(5):436-43. [Medline].

  16. Van Howe RS, Kusnier LP 2nd. Diagnosis and management of pharyngitis in a pediatric population based on cost-effectiveness and projected health outcomes. Pediatrics. Mar 2006;117(3):609-19. [Medline].

  17. Pichichero ME. Pathogen shifts and changing cure rates for otitis media and tonsillopharyngitis. Clin Pediatr (Phila). Jul 2006;45(6):493-502. [Medline].

  18. 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].

  19. 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].

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

  21. [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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Further Reading

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Contributor Information and Disclosures

Author

John R Acerra, MD, Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh; Attending Physician, The Western Pennsylvania Hospital
John R Acerra, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

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.

 
 
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