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

Pharyngitis

John R Acerra, MD, Clinical Instructor, Department of Emergency Medicine, University of Pittsburgh; Attending Physician, The Western Pennsylvania Hospital

Updated: Aug 10, 2009

Introduction

Background

Pharyngitis is defined as an infection or irritation of the pharynx and/or tonsils. The etiology is usually infectious, with most cases being of viral origin. These cases are benign and self-limiting for the most part. Bacterial causes of pharyngitis are also self-limiting, but are concerning because of suppurative and nonsuppurative complications. Other causes include allergy, trauma, toxins, and neoplasia.¹

Streptococcus pyogenes at 100X magnification.

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.

Pathophysiology

With infectious pharyngitis, bacteria or viruses may directly invade the pharyngeal mucosa, causing a local inflammatory response. Other viruses, such as rhinovirus and coronavirus, can cause irritation of pharyngeal mucosa secondary to nasal secretions.²

Streptococcal infections are characterized by local invasion and release of extracellular toxins and proteases. In addition, M protein fragments of certain serotypes of GAS are similar to myocardial sarcolemma antigens and are linked to rheumatic fever and subsequent heart valve damage. Acute glomerulonephritis may result from antibody-antigen complex deposition in glomeruli.³

Frequency

United States

Children experience more than 5 upper respiratory infections (URIs) per year and an average of one streptococcal infection every 4 years. The occurrence in adults is about one half that rate. The most significant bacterial agent causing pharyngitis in both adults and children is GAS infection (Streptococcus pyogenes), and the most common viruses are rhinovirus and adenovirus. GAS is most prevalent in late fall through early spring.¹

International

The incidence of pharyngitis is higher internationally. Antibiotic resistance may be more prevalent in some countries because of overprescription of antibiotics. Note, however, that despite this, there has never been a documented case of GAS resistant to penicillin anywhere in the world.⁴

Mortality/Morbidity

• In the developing world, an estimated 20 million people are affected by acute rheumatic fever and rheumatic heart disease, making this the leading cause of cardiac death during the first 5 decades of life. This incidence of rheumatic heart disease is dramatically lower in most developed countries, but localized outbreaks have occurred in the Western world. Despite this, new cases of rheumatic heart disease in the United States are extremely rare.⁵
• Other sequelae of streptococcal pharyngitis include acute glomerulonephritis, peritonsillar abscess, and toxic shock syndrome.
• Mortality from pharyngitis is rare but may result from one of its complications, most notably airway obstruction.

Age

Pharyngitis occurs with much greater frequency in the pediatric population. Approximately 15-30% of pharyngitis cases among school-aged children in the cooler months are due to GAS. Only 10% of adult cases of pharyngitis are due to GAS.¹  

• The peak incidence of bacterial and viral pharyngitis occurs in the school-aged child aged 4-7 years.
• Pharyngitis, especially GAS infection, is rare in children younger than 3 years.
• Mycoplasma pneumoniae, Chlamydia pneumoniae, and Arcanobacterium haemolyticus are other bacterial causes of pharyngitis, but these pathogens are rare. Antibiotics covering atypical pathogens should not routinely be used to treat pharyngitis.²

Clinical

History

Viral and bacterial causes of pharyngitis are similar, and the differentiation of the etiology is difficult based on history and physical examination alone. Despite this, classic presentations are described below.

• GAS infection is most common in children aged 4-7 years.
• Sudden onset is consistent with a GAS pharyngitis. Pharyngitis following several days of coughing or rhinorrhea is more consistent with a viral etiology.
• Person has been in contact with others diagnosed with GAS or rheumatic fever.
• Headache is consistent with GAS infection.
• Cough is not usually associated with GAS infection.
• Vomiting is associated with GAS infection but may be present in other types of pharyngitis.
• A history of recent orogenital contact suggests the possibility of gonococcal pharyngitis.
• A history of rheumatic fever is important when considering treatment.

• Fever
• Anterior cervical lymphadenopathy
• Tonsillar exudate
• Absence of cough

Physical

• Airway patency must be assessed and addressed first.
• Temperature: Fever is usually absent or low-grade in viral pharyngitis, but fever is not reliable to differentiate viral or bacterial etiologies.
• Hydration status: Oral intake usually is compromised because of odynophagia; therefore, various degrees of dehydration result.
• Head, ears, eyes, nose, and throat (HEENT)
  • Conjunctivitis may be seen in association with adenovirus.
  • Scleral icterus may be seen with infectious mononucleosis.
  • Rhinorrhea usually is associated with a viral cause.
  • Tonsillopharyngeal/palatal petechiae are seen in GAS infections and infectious mononucleosis.
  • A tonsillopharyngeal exudate may be seen in streptococcal infectious mononucleosis and occasionally in M pneumoniae, C pneumoniae, A haemolyticus, adenovirus, and herpesvirus infections. Therefore, exudate does not differentiate viral and bacterial causes.
  • Oropharyngeal vesicular lesions are seen in coxsackievirus and herpesvirus. Concomitant vesicles on the hands and feet are associated with coxsackievirus (hand-foot-and-mouth disease).
• Lymphadenopathy: Tender anterior cervical nodes are consistent with streptococcal infection, whereas generalized adenopathy is consistent with infectious mononucleosis or the acute lymphoglandular syndrome of HIV infection.
• Cardiovascular: Murmurs should be documented in an acute episode of pharyngitis to monitor for potential rheumatic fever.
• Pulmonary: Pharyngitis and lower respiratory tract infections are more consistent with M pneumoniae or C pneumoniae, particularly when a persistent nonproductive cough is present.
• Abdomen: Hepatosplenomegaly can be found in infectious mononucleosis infection.
• Skin
  • A sandpapery scarlatiniform rash is seen in GAS infection (see Scarlet Fever).⁹
  • Maculopapular rashes are seen with various viral infections and with infectious mononucleosis empirically treated with penicillin.

Causes

• Bacterial pharyngitis
  • Group A beta-hemolytic streptococci: The classic clinical picture includes a fever, temperature of greater than 101.5°F; tonsillopharyngeal erythema and exudate; swollen, tender anterior cervical adenopathy; headache; emesis in children; palatal petechiae; midwinter to early spring season; and absent cough or rhinorrhea.⁹
  • Group C, G, and F streptococci may be indistinguishable clinically from GAS infection. Acute glomerulonephritis is an extremely unusual complication of group C streptococcal pharyngitis, but a relationship between group G streptococcal pharyngitis and acute glomerulonephritis has not be established. Acute rheumatic fever has not been described as a complication of either. They may be associated with food-borne outbreaks. The benefit of antibiotic therapy with these types of streptococci is unproven at this time.⁵
  • Arcanobacterium (Corynebacterium) haemolyticus is more common in young adults and is very similar to GAS infection, including a similar scarlatiniform rash. Patients often have a cough. Occasional outbreaks have been reported.
  • M pneumoniae in young adults presents with headache, pharyngitis, and lower respiratory symptoms. Approximately 75% of patients have a cough, which is distinctive from GAS infection.
  • C pneumoniae has a clinical picture similar to that of M pneumoniae. Pharyngitis usually precedes the pulmonary infection by about 1-3 weeks.
  • Neisseria gonorrhoeae is a rare cause of pharyngitis. A careful history is important since infection usually follows orogenital contact. It may be associated with severe systemic infection.
  • Corynebacterium diphtheriae is rare in the United States. A foul-smelling gray-white pharyngeal membrane may result in airway obstruction.
• Viral pharyngitis³
  • Adenovirus: The distinguishing feature of an adenovirus infection is conjunctivitis associated with pharyngitis (pharyngoconjunctival fever). It is the most common etiology in children younger than 3 years.
  • Herpes simplex: Vesicular lesions (herpangina), especially in young children, are the hallmark. In older patients, pharyngitis may be indistinguishable from GABHS infection.
  • Coxsackieviruses A and B: These infections present similarly to herpes simplex, and vesicles may be present. If vesicles are whitish and nodular, it is known as lymphonodular pharyngitis. Coxsackievirus A16 may cause hand-foot-and-mouth disease, which presents with 4- to 8-mm oropharyngeal ulcers and vesicles on the hands and feet, and, occasionally, on the buttocks. The oropharyngeal ulcers and vesicles resolve within 1 week.
  • Epstein-Barr virus (EBV): Clinically known as infectious mononucleosis, it is extremely difficult to distinguish from GAS infection. Exudative pharyngitis is prominent. Distinctive features include retrocervical or generalized adenopathy and hepatosplenomegaly. Atypical lymphocytes can be seen on peripheral blood smear. Viral cultures from washings are about 20% sensitive in adults.
  • CMV: Presentation of CMV is similar to the presentation of infectious mononucleosis. Patients tend to be older, are sexually active, and have higher fever and more malaise. Pharyngitis may not be a prominent complaint.
  • HIV-1: This is associated with pharyngeal edema and erythema, common aphthous ulcers, and a rarity of exudates. Fever, myalgia, and lymphadenopathy also are found.
• Other causes of pharyngitis
  • Oral thrush is due to candidal species, usually in patients who are immunocompromised. It may be common in young children and presents with whitish plaques in the oropharynx.
  • Other causes include dry air, allergy/postnasal drip, chemical injury, gastroesophageal reflux disease (GERD), smoking, neoplasia, and endotracheal intubation.

Differential Diagnoses

Other Problems to Be Considered

Allergic rhinitis with postnasal drip
Airway obstruction
Head and neck neoplasias
Gastroesophageal reflux disease (GERD)
Peritonsillar cellulitis

Workup

Laboratory Studies

• GABHS rapid antigen detection test

Rapid antigen detection test for group A beta-hemolytic streptococci.

• This is the preferred method for diagnosing GAS infection in the emergency department because of difficulties with culture follow-up.
• Only patients with a high clinical likelihood of GAS pharyngitis should be tested. Patients with a Centor score of 0-1 should be treated symptomatically without testing.¹⁰
• Antigens are specific, but sensitivities vary. Children with a negative antigen test should have a follow-up culture unless the antigen being used in the office has been shown to be as sensitive as a culture.⁹
• Adults do not need follow-up culture after a negative antigen test because of the low incidence of GAS in this population.¹¹
• Throat culture
  • This is the criterion standard for diagnosis of GAS infection (90-99% sensitive). Although less expensive than the rapid antigen detection test, it is not be the best test to use in the emergency department because of difficulty with follow-up. The guidelines that recommend cultures for GAS screening are aimed at office-based practices and not the emergency department.
  • Patients can be treated up to 9 days after onset of symptoms to prevent acute rheumatic fever, so immediate antibiotic therapy is not crucial if patients can be easily contacted for follow-up should a culture become positive.¹
• Mono spot is up to 95% sensitive in children (less than 60% sensitivity in infants).
• Peripheral smear may show atypical lymphocytes in infectious mononucleosis.²
• Perform gonococcal culture, as indicated by history.
• A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein have a low predictive value and usually are not indicated.

Imaging Studies

• Imaging studies generally are not indicated for uncomplicated viral or streptococcal pharyngitis.
• Lateral neck film should be taken in patients with suspected epiglottitis or airway compromise.
• Soft tissue neck CT should be used if concern for abscess or deep-space infection exists.

Procedures

• The procedure for a throat swab is to vigorously rub a dry swab over the posterior pharynx and both tonsils, obtaining a sample of exudate. If any exudate is obtained, then transport it dry (not in a liquid medium).

Treatment

Prehospital Care

• Prehospital care usually is not necessary for uncomplicated pharyngitis unless airway compromise is an issue.
• Intubation should not be attempted unless the patient stops breathing spontaneously.

Emergency Department Care

• Assess and secure the airway, if necessary.
• Assess the patient for signs of toxicity, epiglottitis, or oropharyngeal abscess.¹²
• Evaluate the hydration status because severe pharyngitis limits oral intake.  Appropriate measures to rehydrate should be initiated, including intravenous hydration.
• Assess for GAS infection if clinically suspected. A suggested algorithm as is follows.
  • In general, patients should not be treated without a positive culture or positive rapid antigen detection test result because of increasing antibiotic resistance. Guidelines from the Infectious Diseases Society of America (IDSA) and American Heart Association state that microbiologic confirmation (via a rapid antigen test or culture) is required for the diagnosis of GAS.^7,5  New recommendations for pharyngitis therapy are due from the IDSA later in 2009.
  • Perform rapid antigen detection test if GAS is clinically suspected based on history and physical examination. If positive, begin antibiotic therapy. Testing does not usually need to be performed on patients with acute pharyngitis whose clinical and epidemiologic features do not suggest GAS as the etiology (Centor score 0-1).¹¹
  • Household contacts of patients with GAS infection or scarlet fever should be treated for a full 10 days without testing only if they have symptoms consistent with GAS.⁵
  • If clinically doubtful or the above criteria are not met, it is best to await rapid antigen or culture results to initiate antibiotic therapy.

Consultations

With a few exceptions, uncomplicated cases of pharyngitis should not require a consultation. Infectious disease specialists should be consulted in the case of unusual presentation or in the case of a patient who is immunocompromised.

Medication

GAS pharyngitis is usually a self-limited disease, and most signs and symptoms resolve spontaneously in 3-4 days. If administered early, antibiotics can shorten the duration of the illness by up to 1 day, but the main reason they are given is for prevention of acute rheumatic fever.¹³ This rationale is being questioned by many as the incidence of acute rheumatic fever in the United States is extremely low. Antibiotics do not prevent acute glomerulonephritis. Steroids may be used for airway compromise and symptomatic relief.¹⁴  Antifungals and antivirals are used in certain rare cases with specialist consultation.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotics are indicated for clinically suspected and culture or antigen-verified GAS infection. They are effective in preventing rheumatic fever if given within 9 days of the onset of pharyngitis.

Of note, some experts question the use of antibiotics for the treatment of GAS infection in the Western world because of the low prevalence of rheumatic fever. Some European guidelines for the treatment of pharyngitis only recommend antibiotics for patients with culture-positive GAS pharyngitis who are high-risk for acute rheumatic fever or very ill.¹⁵ One study suggested that observation alone was most cost-effective strategy for GAS pharyngitis in children, and this strategy also had lower morbidity and mortality than antibiotic treatment groups.¹⁶ For now, most experts in the United States still recommend treatment with antibiotics.

Some support the use of cephalosporins instead of penicillin as first-line therapy for GAS.^17,18 They cite literature that shows greater eradication of the bacteria in the pharynx after treatment with a cephalosporin. No evidence suggests that this is clinically significant, and most guidelines still advocate that penicillin is still the drug of choice for GAS in the United States. There has never been a clinical isolate of GAS documented to be resistant to penicillin anywhere in the world.⁷ In cases of clinical treatment failure of GAS pharyngitis after penicillin therapy, a cephalosporin or broader-spectrum penicillin (ampicillin-sulbactam) should be considered, but these instances are rare.¹² Cephalosporins should be considered first-line therapy if the patient has a history of recent antibiotic usage, recurrent pharyngitis infection, a penicillin allergy, or if a high failure rate of penicillin is documented in the community.¹⁹

Some controversy exists regarding the treatment of carriers of GAS. These are patients who have a positive rapid antigen or culture without symptoms of pharyngitis. It is believed that this carrier state does not lead to acute rheumatic fever or other complications of GAS pharyngitis. Most carriers should not be treated; however, treatment should be considered in carriers with the following characteristics:

• Recurrent pharyngitis without cough or congestion
• Acute rheumatic fever (ARF) or poststreptococcal glomerulonephritis outbreaks
• GAS pharyngitis in closed community
• Family history of ARF
• Multiple documented GAS pharyngitis episodes within a family over several weeks despite therapy

While some literature exists to support the use of a shorter course of antibiotic therapy for GAS pharyngitis, most international guidelines still recommend a 10-day course for most antibiotics.²¹ This may change shortly as new guidelines are due in 2009 from the Infectious Diseases Society of America (IDSA).

Penicillin G benzathine (Bicillin LA)

Inhibits biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations reached, and most effective during stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Still is drug of choice in GAS pharyngitis because of its narrow spectrum of activity, low cost, and proven safety track record. IM penicillin is drug of choice in patients where compliance is an issue because of single dose.

Dosing

Adult

1.2 million U IM (single dose)

Pediatric

25,000 U/kg IM; not to exceed 1.2 million U

Interactions

Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects

Contraindications

Documented hypersensitivity

Precautions

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 and seizure disorder

Penicillin VK (Beepen-VK)

Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached. Most effective during stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Poor patient compliance due to dosing frequency and duration plagues this drug regimen. However, tid dosing is shown in some studies to be as effective as qid dosing. For recurrent streptococcal infections, a combination of penicillin VK and rifampin may be used. Rifampicin, 20 mg/kg/d for 4 d, is added to the standard 10-d treatment with penicillin.

Dosing

Adult

500 mg PO bid for 10 d

Pediatric

<27kg body weight: 250 mg PO bid/tid for 10 d
>27kg body weight: Administer as in adults

Interactions

Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of penicillins when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in renal impairment and seizure disorder

Amoxicillin (Amoxil, Biomox, Trimox)

Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria. Associated with higher incidence of rash. No advantage over oral penicillin, but sometimes more acceptable to children because of taste. Some studies suggest that once-daily dosing of amoxicillin is adequate therapy for GABHS, but further studies are needed to validate this treatment regimen.

Dosing

Adult

500 mg PO bid for 10 d

Pediatric

50 mg/kg/d PO divided bid for 10 d

Interactions

Reduces the efficacy of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

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

Cephalexin (Keflex)

First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora. Used for skin infections or prophylaxis in minor procedures. Choice for patients who are sensitive for penicillin.

Dosing

Adult

250-500 mg PO q6h for 10 d

Pediatric

50 mg/kg/d PO q6h for 10 d; not to exceed 3 g/d

Interactions

Coadministration with aminoglycosides increases nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Administer half dose if creatinine clearance is 10-30 mL/min and one fourth dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy

Azithromycin (Zithromax)

This antibiotic has a higher cost but has a slightly higher effectiveness than erythromycin. Shorter course and one-a-day dosing make this a good alternative for patients who are allergic to penicillin.

Dosing

Adult

500 mg PO qd for 5 d

Pediatric

12 mg/kg/d PO qd for 5 d; not to exceed 500 mg/dose

Interactions

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

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; 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 or debilitated and in geriatric patients

Erythromycin (EES, Erythrocin, Ery-Tab)

Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria (eg, M pneumoniae, C pneumoniae, A haemolyticus), which generally are not sensitive to penicillin. Indicated for patients allergic to penicillin. GABHS resistance is generally thought to be less than 5% in the United States, but more recent studies show resistance rates of up to 30%.

Dosing

Adult

500 mg PO qid for 10 d
A haemolyticus: 250 mg PO qid for 10 d if resistant to penicillin

Pediatric

40-50 mg/kg/d PO divided qid for 10 d; not to exceed 2 g/d

Interactions

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

Contraindications

Documented hypersensitivity; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI side effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Clindamycin (Cleocin)

Semisynthetic antibiotic produced by 7(S)-chloro-substitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys.
Used for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). More effective than penicillin in eliminating chronic streptococcal carriage. Recommended for treatment of symptomatic people with multiple, recurrent episodes of GABHS pharyngitis confirmed by rapid antigen testing or culture.

Dosing

Adult

20 mg/kg/d PO divided tid; 1800 mg/d maximum

Pediatric

20 mg/kg/d PO divided tid; 1800 mg/d maximum

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption of clindamycin

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

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

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins. Indicated for cases of gonococcal pharyngitis. Dosing is different for neonatal gonorrhea.

Dosing

Adult

250 mg IM once

Pediatric

25-50 mg/kg IM once, not to exceed 250 mg

Interactions

Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

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; caution in breastfeeding women and in patients allergic to penicillin

Corticosteroids

The role of steroids in acute pharyngitis remains controversial. Steroids are used in cases of airway obstruction. They have been shown in several studies to reduce clinical symptoms and to shorten the clinical course. They should be used selectively for patients with significant swelling or odynophagia.¹⁴  Steroids are useful in thrombocytopenia or hemolytic anemia induced by EBV in infectious mononucleosis.

Dexamethasone (Decadron)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. For pharyngitis, steroids must be administered in conjunction with antibiotics. Provides symptomatic relief for severe pharyngitis. A one-time IM dose is convenient and avoids compliance issues. Betamethasone is an alternative to dexamethasone.

Dosing

Adult

8-16 mg IM once

Pediatric

0.08-0.3 mg/kg IM once

Interactions

Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization

Contraindications

Documented hypersensitivity; viral, fungal, tubercular skin, and connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI disease

Precautions

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

Increases risk of multiple complications, including severe infections; monitor adrenal insufficiency when tapering drug; abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections are possible complications of glucocorticoid use

Prednisone (Deltasone, Orasone, Sterapred)

May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Inactive and must be metabolized to the active metabolite prednisolone. The conversion may be impaired in patients with liver disease.

Dosing

Adult

20-60 mg/d PO qd for 5 d

Pediatric

4-5 mg/m²/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; for 5 d

Interactions

Coadministration with estrogens may decrease clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Contraindications

Documented hypersensitivity; viral, fungal, tubercular skin, and connective tissue infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Antifungals

These agents are indicated for cases of pharyngitis associated with oral thrush.

Nystatin (Mycostatin)

Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlike fungi. Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak. Treatment should continue until 48 h after disappearance of symptoms.

Dosing

Adult

400,000-600,000 U swish and swallow 4-5 times/d

Pediatric

Administer as in adults

Interactions

None reported

Contraindications

Documented hypersensitivity

Precautions

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

Do not use to treat systemic mycoses

Fluconazole (Diflucan)

Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal CYP-450 and sterol C-14 alpha-demethylation.

Dosing

Adult

200 mg PO once, then 100 mg qd for 14 d

Pediatric

3-6 mg/kg PO qd for 14-28 d or 6-12 mg/kg qd, depending on severity of infection

Interactions

Levels may increase with hydrochlorothiazide; fluconazole levels may decrease with chronic coadministration of rifampin; coadministration of fluconazole may decrease phenytoin concentrations; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with fluconazole coadministration; increases in cyclosporine concentrations may occur when administered concurrently

Contraindications

Documented hypersensitivity

Precautions

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

Closely monitor if rashes develop, and discontinue drug if lesions progress; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) when taken with underlying medical conditions (eg, AIDS, malignancy) and while taking multiple concomitant medications; not recommended for breastfeeding mothers

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.

Multimedia

Media file 1: Streptococcus pyogenes at 100X magnification.

Media file 2: Rapid antigen detection test for group A beta-hemolytic streptococci.

Media file 3: 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.

References

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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].

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Keywords

pharyngitis, infection of pharynx, irritation of pharynx, infection of tonsils, irritation of tonsils, group A beta-hemolytic streptococcal infections, GABHS infections, bacterial pharyngitis, viral pharyngitis, acute rheumatic fever, acute glomerulonephritis, upper respiratory infections, heart valve damage, Streptococcus pyogenes, rhinovirus, adenovirus, peritonsillar abscess, toxic shock syndrome, Mycoplasma pneumoniae, Chlamydia pneumoniae, Arcanobacterium haemolyticus, rhinorrhea, gonococcal pharyngitis, coxsackievirus A, coxsackievirus B, herpes simplex, infectious mononucleosis, cytomegalovirus, CMV, odynophagia, tonsillopharyngeal petechiae, palatal petechiae, hand-foot-and-mouth disease, cervical lymphadenopathy, acute lymphoglandular syndrome, hepatosplenomegaly, scarlet fever, meningitis, endocarditis, subdural empyemas, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Epstein-Barr virus, EBV, HIV-1, oral thrush, gastroesophageal reflux disease, GERD, endotracheal intubation, allergy, postnasal drip

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.

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.

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