eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Pharyngitis: Follow-up

Author: Harold K Simon, MD, MBA, Professor of Pediatrics and Emergency Medicine, Associate Division Director of Pediatric Emergency Medicine, Director of Research, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston
Contributor Information and Disclosures

Updated: Oct 21, 2009

Follow-up

Further Inpatient Care

  • Rarely, small children with pharyngitis who have signs and symptoms of dehydration after refusing to drink may require hospitalization for intravenous hydration. Usually, even patients who require intravenous hydration in the ED consume enough oral fluids following their intravenous fluid bolus to allow home management.

Further Outpatient Care

  • Because more than 90% of children clear group A beta-hemolytic streptococci (GABHS) from their pharynx within 24 hours of antibiotic therapy initiation, they should remain out of school or daycare for 1 day.
  • Reevaluate the patient if symptoms persist for more than 24-48 hours.
  • Follow-up cultures are not routinely necessary unless concerns arise regarding recurrences or carrier states.
  • Instruct families to encourage adequate hydration and to use antipyretics for pain and fever. Also instruct parents to seek immediate medical care or consult their primary medical provider if signs of dehydration occur or symptoms worsen.

Inpatient & Outpatient Medications

  • In addition to adequate antibiotic therapy for patients with GABHS, administer antipyretics in all patients for pain and fever, irrespective of etiology. Ibuprofen (10 mg/kg/dose orally every 8 h) or acetaminophen (15 mg/kg/dose orally every 4-6 h) is effective.
  • For patients with herpangina (stomatitis/pharyngitis), alumina/magnesia (Maalox) and diphenhydramine hydrochloride (Benadryl) mixed in a 1:1 ratio can be orally administered before meals to decrease associated discomfort and to help maintain good hydration. This medication can be dosed based on the Benadryl component (1.25 mg/kg/dose oral swish and swallow every 6 h as needed).

Complications

  • Although the prevention of rheumatic fever is the primary reason for treating GABHS, several interesting facts were found during outbreaks of rheumatic fever in 1985 and 1990.
  • No previous significant increases in GABHS were noted in the communities prior to the outbreaks. The outbreaks were observed in middle-class areas, where compliance rates with medical therapy are relatively high.
  • Unlike most previous outbreaks, severe pharyngitis was rarely noted, and only 46% reported even having a recent sore throat. Only 24% of patients had sore throats serious enough to seek medical care. In addition, almost 20% of cases were in children who received antibiotics for pharyngitis (type of antibiotic, length of therapy, and compliance issues were not recorded).
  • Therefore, outbreaks may, in fact, be most related to the "rheumatigenicity" of the GABHS.

Prognosis

  • Prognosis is excellent for all types of pharyngitis. In rare cases, rheumatic fever can develop if GABHS is left untreated. Rarely, peritonsillar abscesses or other local complications develop. With supportive care to prevent dehydration and pain, pharyngitis, for the most part, is a self-limiting disease.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Potential for medical/legal pitfalls primarily involves missed diagnoses or failure to treat group A beta-hemolytic streptococci (GABHS). The complications are rare and usually occur during outbreaks of rheumatic heart disease; however, failure to diagnose and treat within the 9-day window from the start of symptoms can leave one open to potential litigation.
 


More on Pharyngitis

Overview: Pharyngitis
Differential Diagnoses & Workup: Pharyngitis
Treatment & Medication: Pharyngitis
Follow-up: Pharyngitis
Multimedia: Pharyngitis
References
[ CLOSE WINDOW ]

References

  1. [Guideline] Michigan Quality Improvement Consortium. Acute pharyngitis in children. Southfield (MI): Michigan Quality Improvement Consortium; 2009 Jan. [Full Text].

  2. Fretzayas A, Moustaki M, Kitsiou S, Nychtari G, Nicolaidou P. The clinical pattern of group C streptococcal pharyngitis in children. J Infect Chemother. Aug 2009;15(4):228-32. [Medline].

  3. American Academy of Pediatrics. Report of the committee on infectious diseases. Pickering LK, Baker CJ, McMillan J, Long S (Editors). Red Book. 27th Edition. Elk Grove Village, Il: American Academy of Pediatrics; 2006:430-439.

  4. el-Daher NT, Hijazi SS, Rawashdeh NM, et al. Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V. Pediatr Infect Dis J. Feb 1991;10(2):126-30. [Medline].

  5. Wannamaker LW, Rammelkamp CH Jr, 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].

  6. Bulloch B, Kabani A, Tenenbein M. Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med. May 2003;41(5):601-8. [Medline].

  7. Chi H, Chiu NC, Li WC, Huang FY. Etiology of acute pharyngitis in children: is antibiotic therapy needed?. J Microbiol Immunol Infect. Mar 2003;36(1):26-30. [Medline].

  8. Denny FW, Wannamaker LW, Brink WR, et al. Landmark article May 13, 1950: Prevention of rheumatic fever. Treatment of the preceding streptococcic infection. JAMA. Jul 26 1985;254(4):534-7. [Medline].

  9. Edress D. Dosing Handbook. 4th ed. Egleston Scottish Rite Children's Healthcare System; 1999-2000.

  10. Feder HM Jr, Gerber MA, Randolph MF, et al. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics. Jan 1999;103(1):47-51. [Medline]. [Full Text].

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

  12. Gerber MA, Markowitz M. Management of streptococcal pharyngitis reconsidered. Pediatr Infect Dis. Sep-Oct 1985;4(5):518-26. [Medline].

  13. Krober MS, Weir MR, Themelis NJ, van Hamont JE. Optimal dosing interval for penicillin treatment of streptococcal pharyngitis. Clin Pediatr (Phila). Nov 1990;29(11):646-8. [Medline].

  14. Marvez-Valls EG, Stuckey A, Ernst AA. A randomized clinical trial of oral versus intramuscular delivery of steroidsin acute exudative pharyngitis. Acad Emerg Med. Jan 2002;9(1):9-14. [Medline].

  15. 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].

  16. Pichichero ME. Controversies in the treatment of streptococcal pharyngitis. Am Fam Physician. Dec 1990;42(6):1567-76. [Medline].

  17. Roosevelt GE, Kulkarni MS, Shulman ST. Critical evaluation of a CLIA-waived streptococcal antigen detection test inthe emergency department. Ann Emerg Med. Apr 2001;37(4):377-81. [Medline].

  18. Smeesters PR, Campos D, Van Melderen L, et al. Pharyngitis in low-resources settings: a pragmatic clinical approach to reduce unnecessary antibiotic use. Pediatrics. Dec 2006;118(6):e1607-11. [Medline].

  19. Snellman LW, Stang HJ, Stang JM, et al. Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics. Jun 1993;91(6):1166-70. [Medline].

  20. 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].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

pharyngitis, sore throat, tonsillitis, tonsillopharyngitis, nasopharyngitis, pharyngeal inflammation, group A beta-hemolytic streptococci, GABHS, GABHS pharyngitis, viral pharyngitis, rheumatic fever, rhinorrhea, laryngitis, adenoviruses, enteroviruses, treatment, diagnosis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Harold K Simon, MD, MBA, Professor of Pediatrics and Emergency Medicine, Associate Division Director of Pediatric Emergency Medicine, Director of Research, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta at Egleston
Harold K Simon, MD, MBA is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Pediatric Society, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.