Pharyngitis in Emergency Medicine Workup

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

Laboratory Studies

  • GABHS rapid antigen detection testRapid antigen detection test for group A beta-hemoRapid 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.[11]
    • 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]
    • The use of a GABHS rapid antigen detection test can decrease the use of unnecessary antibiotics in pediatric patients when used properly.[12]
    • Adults do not need follow-up culture after a negative antigen test because of the low incidence of GAS in this population.[13]
  • 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.
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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 can be used if concern for abscess or deep-space infection exists; however, peritonsillar abscess is almost always a clinical diagnosis. Imaging is rarely needed for diagnosis.
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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).
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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

  1. Alcaide AL, Bisno AL. Pharyngitis and epiglottitis. 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. [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].

  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. 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].

  13. 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].

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

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

  16. 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].

  17. 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].

  18. 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].

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

  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].

  24. Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Ann Fam Med. Jan-Feb 2010;8(1):58-63. [Medline].

  25. Hayward G, Thompson M, Heneghan C, Perera R, Del Mar C, Glasziou P. Corticosteroids for pain relief in sore throat: systematic review and meta-analysis. BMJ. Aug 6 2009;339:b2976. [Medline].

  26. Wing A, Villa-Roel C, Yeh B, Eskin B, Buckingham J, Rowe BH. Effectiveness of Corticosteroid Treatment in Acute Pharyngitis: A Systematic Review of the Literature. Acad Emerg Med. 2010;17(5):476-483.

 
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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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