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Pediatrics, Pharyngitis: Treatment & Medication
Updated: Jan 28, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Emergency Department Care
- For patients with viral etiologies for their pharyngitis, care should be supportive, with antipyretics, analgesics, and measures to guarantee good hydration. IV fluids may be necessary.
- For patients with GABHS, the criterion standard therapy is PCN. Based on the availability of rapid testing for GABHS and the clinical severity of the patient, one can decide between initiating therapy if a rapid test is positive for GABHS or delaying therapy until culture results are obtained if no rapid testing is available.
- The issue of early versus delayed therapy for GABHS pharyngitis, until cultures can be obtained, has several considerations.
- Early therapy (within 48 hours of symptoms) appears to shorten the duration of symptoms, limit the spread to others, allow the patient and family to return to their usual routine sooner, and limit losses to follow up.
- Cons for early therapy before rapid GABHS screen or throat culture results can be obtained include the following:
- Early therapy may lead to a higher failure rate secondary to an inability to create an immune response to the infection.
- Rheumatic fever can be prevented even if antibiotic therapy is initiated as late as 9 days from the onset of symptoms.
- Possible drug reactions may occur.
- Expenses can be avoided by not immediately treating cases that are caused by pathogens other than GABHS.
- Therefore, decisions on treatment must be individualized based on available testing, severity of symptoms, comfort with the availability to arrange follow-up care, and the need for the patient and the family to quickly return to their regular routine (eg, school, daycare).
Consultations
- Refer to ear, nose, and throat (ENT) specialist for possible tonsillectomy if pharyngitis is recurrent or severe.
- Refer to the primary care physician for follow-up care.
Medication
The criterion standard for treatment of GABHS pharyngitis is penicillin (PCN) in conjunction with supportive care for pain, fever, and prevention of dehydration. Ampicillin or amoxicillin often have been used in place of PCN; however, no microbiologic advantages exist over PCN therapy. Compliance has been better with bid/tid PCN than with traditional qid regimens. Amoxicillin taken once daily has even been shown effective in a recent preliminary report.
Cephalosporins also have been used with questionably improved failure rates compared with PCN. Cephalosporins resist degradation by beta-lactamases and are very effective against copathogens. First- or second-generation cephalosporins are best. Some of the cephalosporins include cephalexin, cefadroxil, cefuroxime, cefixime, cefdinir, and cefpodoxime.
Macrolide antibiotics are recommended for penicillin-allergic patients.
Recently, corticosteroids (oral dexamethasone) have been suggested as an adjunct therapy to decrease pain and length of symptoms in adults with pharyngitis. The one randomized controlled study in children found that the use of single-dose oral dexamethasone (0.6 mg/kg, not to exceed 10 mg) did not decrease the time to onset of clinically significant pain relief or time to complete pain relief.1 However, for the subset of children with positive rapid strep test results, a statistically significant (but marginally clinically significant) improvement in time to onset of pain relief occurred.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.
Penicillin G benzathine (Bicillin L-A, Permapen)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. Effective in over 90% of cases.
Not to be administered IV/IA/SC.
Adult
1,200,000 U IM once
Pediatric
<27.3 kg: 600,000 U IM once
>27.3 kg: Administer as in adults
Alternative dose: 25,000-50,000 U/kg/dose IM; not to exceed 1,200,000 U/dose
Probenecid can increase effects of PCN; coadministration of tetracyclines can decrease effects of PCN
Documented hypersensitivity
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
Penicillin VK (Veetids)
Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached, and most effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Treatment of choice if patients can tolerate PO therapy.
Treatment regimens as low as 2 doses/d are proven effective. Krober et al found failure rates of 31%, 6%, and 11% for qd, bid, and qid dosing, respectively.2
Adult
500 mg PO bid/tid for 10 d
Pediatric
<27.3 kg: 125 mg PO tid/qid for 10 d
>27.3 kg: 250 mg PO tid/qid for 10 d
Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in the effectiveness of PCNs when administered concurrently
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 impairment
Erythromycin (E.E.S., Eryc, Ery-Tab, EryPed)
For PCN allergic patients, the AAP recommends erythromycin ethylsuccinate. (Other macrolides, such as clarithromycin for 10 d or azithromycin for 5 d, have also been approved.)
Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. For treatment of staphylococcal and streptococcal infections.
Adult
400-800 mg PO qid for 10 d
Pediatric
40 mg/kg/d PO divided tid/qid for 10 d
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
Documented hypersensitivity; hepatic impairment
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 adverse effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur
Cefuroxime (Ceftin)
Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and M catarrhalis.
Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.
Administer with food to minimize GI adverse effects.
Adult
250-500 mg PO bid
Pediatric
20 mg/kg PO divided bid; not to exceed 250 mg/d (suspension); or 125 mg PO bid (tab)
Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increase nephrotoxic potential; probenecid increases serum concentrations
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Administer half dose if CrCl is 10-30 mL/min and one-fourth dose if <10 mL/min; fungal and microorganism overgrowth may occur with prolonged therapy; caution in PCN allergy
Cefixime (Suprax)
By binding to one or more of the PCN-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth.
Administer with food to minimize GI adverse effects.
Adult
400 mg PO qd or divided q12h
Pediatric
<50 kg or <12 years: 8 mg/kg susp PO qd or 4 mg/kg PO q12h
>50 kg or >12 years: Administer as in adults
Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use with caution with patients who have a documented hypersensitivity to PCNs.
Use with caution in patients with reduced renal function
GI adverse effects, including nausea and diarrhea, are some of the more common adverse drug reactions
Cefpodoxime proxetil (Vantin)
A second-generation cephalosporin indicated for the management of infections caused by susceptible mixed aerobic-anaerobic microorganisms.
Cefpodoxime inhibits bacterial cell wall synthesis by binding to one or more of the PCN-binding proteins. Bacteria eventually lyse because of the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Adult
100 mg/dose PO q12h
Pediatric
10 mg/kg/d PO divided q12h; not to exceed 200 mg/d
Alcoholic beverages consumed <72 h after taking cefaclor may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics and aminoglycosides (eg, loop diuretics) may increase nephrotoxicity
Documented hypersensitivity
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 PCN allergy; adverse effects include nausea, vomiting, and diarrhea
Cefditoren (Spectracef)
Semi-synthetic cephalosporin administered as prodrug. Hydrolyzed by esterases during absorption and distributed in circulating blood as active cefditoren.
Bactericidal activity results from inhibition of cell wall synthesis via affinity for penicillin-binding proteins.
No dose adjustment necessary for mild renal impairment (CrCl 50-80 mgL/min/1.73 m2) or mild to moderate hepatic impairment.
Indicated for the treatment of acute exacerbation of pharyngitis/tonsillitis caused by susceptible strains of Streptococcus pyogenes.
Adult
200 mg PO with meals bid for 10 d
Moderate renal impairment (CrCl 30-49 mL/min/1.73 m2: No more than 200 mg PO bid
Severe renal impairment (CrCl <30 mL/min/1.73 m2): 200 mg PO qd
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Absorption reduced with H2 receptor antagonists and antacids of magnesium and aluminum hydroxides may reduce absorption; probenecid may increase plasma concentrations of cefditoren
Documented hypersensitivity to drug, penicillin, related compounds, or milk protein sodium caseinate; carnitine deficiency or inborn errors of metabolism that may result in clinically significant carnitine deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause diarrhea, nausea, and vaginal moniliasis (yeast infection); pseudomembranous colitis may occur; clinical manifestations of carnitine deficiency may occur with prolonged use; prolonged use may result in emergence and overgrowth of resistant organisms; caution in breastfeeding
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Treats mild-to-moderate microbial infections.
Shorter course and one-a-day dosing make this a good alternative for patients who are sensitive to penicillin.
Adult
500 mg PO qd for 4-5 d
Pediatric
12 mg/kg/d PO qd for 5 d; not to exceed 500 mg/d
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
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
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
Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Rifampin (Rifadin)
Recommended in conjunction with PCN for recurrent GABHS and for carrier states.
Inhibits DNA-dependent RNA polymerase activity in susceptible cells. Specifically, it interacts with bacterial RNA polymerase but does not inhibit the mammalian enzyme.
Take on an empty stomach.
Adult
10 mg/kg/d PO as a single dose; not to exceed 600 mg/d
Pediatric
20 mg/kg/d PO divided qid for last 4 d of 10-d therapy with penicillin VK or 10 mg/kg PO q12h for 4 d in conjunction with penicillin G benzathine
Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)
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
Obtain CBCs and baseline clinical chemistries prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur; may discolor the urine, tears, sweat, or other body fluids
Cephalexin (Keflex)
First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.
Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococcal or staphylococci, including penicillinase-producing staphylococci. May use to initiate therapy when streptococcal or staphylococcal infection is suspected.
Used orally when outpatient management is indicated. At least as effective as erythromycin in eradicating GABHS infection.
Adult
250-1000 mg PO q6h for 10 d
Pediatric
50 mg/kg/d PO divided q6h for 10 d; not to exceed 3 g/d
Coadministration with aminoglycosides increases nephrotoxic potential
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections, and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy
Clindamycin (Cleocin)
Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Used for recurrent GABHS pharyngitis or in cases of carrier state.
Take capsule with full glass of water.
Adult
150-450 mg PO q6-8h
Pediatric
20 mg/kg/d PO divided tid for 10 d; not to exceed 1.8 g/d
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis, ulcerative colitis, hepatic impairment, antibiotic-associated colitis
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
Corticosteroids
These agents have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Dexamethasone (Decadron)
Has many pharmacologic benefits but significant adverse effects. Stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines (eg, TNF-alpha, IL-6, IL-2, and IFN-gamma). The inhibition of chemotactic factors and factors that increase capillary permeability inhibits recruitment of inflammatory cells into affected areas. Suppresses lymphocyte proliferation through direct cytolysis and inhibits mitosis. Breaks down granulocyte aggregates, and improves pulmonary microcirculation. For symptom relief in patients with severe exudative pharyngitis.
Adverse effects are hyperglycemia, hypertension, weight loss, GI bleeding or perforation synthesis, cerebral palsy, adrenal suppression, and death. Most of the adverse effects of corticosteroids are dose-dependent or duration-dependent.
Readily absorbed via the GI tract and metabolized in the liver. Inactive metabolites are excreted via the kidneys. Lacks salt-retaining property of hydrocortisone.
Patients can be switched from an IV to PO regimen in a 1:1 ratio.
Adult
10 mg IM single dose
Pediatric
0.6 mg/kg PO/IM single dose; not to exceed 10 mg
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; dexamethasone decreases effect of salicylates and vaccines used for immunization
Documented hypersensitivity; active bacterial or fungal infection
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
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| Differential Diagnoses & Workup: Pediatrics, Pharyngitis |
 Treatment & Medication: Pediatrics, Pharyngitis |
| Follow-up: Pediatrics, Pharyngitis |
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References
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Krober MS, Weir MR, Themelis NJ, et al. Optimal dosing interval for penicillin treatment of streptococcal pharyngitis. Clin Pediatr (Phila). Nov 1990;29(11):646-8. [Medline].
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Marvez-Valls EG, Stuckey A, Ernst AA. A randomized clinical trial of oral versus intramuscular delivery of steroids in acute exudative pharyngitis. Acad Emerg Med. Jan 2002;9(1):9-14. [Medline].
Peter G, Smith AL. Group A streptococcal infections of the skin and pharynx (second of two parts). N Engl J Med. Aug 18 1977;297(7):365-70. [Medline].
Pichichero ME. Controversies in the treatment of streptococcal pharyngitis. Am Fam Physician. Dec 1990;42(6):1567-76. [Medline].
Roosevelt GE, Kulkarni MS, Shulman ST. Critical evaluation of a CLIA-waived streptococcal antigen detection test in the emergency department. Ann Emerg Med. Apr 2001;37(4):377-81. [Medline].
Snellman LW, Stang HJ, Stang JM. Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics. Jun 1993;91(6):1166-70. [Medline].
Van Cauwenberge PB, Vander Mijnsbrugge A. Pharyngitis: a survey of the microbiologic etiology. Pediatr Infect Dis J. Oct 1991;10(10 Suppl):S39-42. [Medline].
Wannamaker LW, Rammelkamp CH, Denny FW, et al. Prophylaxis of acute rheumatic fever by treatment of the preceding streptococcal infection with various amounts of depot penicillin. Am J Med. Jun 1951;10(6):673-95. [Medline].
Further Reading
Keywords
pharyngitis in children, pharyngitis, group A beta-hemolytic streptococcal pharyngitis, GABHS, group C streptococci, group G streptococci, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Corynebacterium hemolyticum, rhinovirus, adenovirus, parainfluenza virus, coxsackievirus, coronavirus, echovirus, herpes simplex virus, Epstein-Barr virus, mononucleosis, cytomegalovirus, Staphylococcus aureus, Haemophilus influenzae, Branhamella catarrhalis, Bacteroides fragilis, Bacteroides oralis, Bacteroides melaninogenicus,Fusobacterium species, Peptostreptococcus species, Chlamydia trachomatis, Mycoplasma pneumoniae
