eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Pharyngitis

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

Updated: Oct 21, 2009

Introduction

Background

Pharyngitis is a leading cause of pediatric ambulatory care visits. Examination of patients who present with sore throat may reveal tonsillitis, tonsillopharyngitis, or nasopharyngitis.¹ The absence of pharyngeal inflammation or the presence of either rhinorrhea or laryngitis is much more likely to be associated with viral infection. However, no physical findings clearly separate group A beta-hemolytic streptococci (GABHS) from viral, other bacterial, or noninfectious causes.

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

Multiple etiologies can cause irritation and inflammation of the pharynx. Causes in children range from viruses (eg, adenoviruses, enteroviruses, Epstein-Barr virus [EBV]), which often require only supportive therapy, to bacterial pathogens (eg, GABHS), which require antibiotic therapy. GABHS pharyngitis is spread via respiratory droplets through close contact.

No pathogen is isolated in nearly 30% of cases, and viruses are isolated in approximately 40% of cases. Other probable copathogens in children include Staphylococcus aureus, Haemophilus influenzae, Branhamella catarrhalis, Bacteroides fragilis, Bacteroides oralis, Bacteroides melaninogenicus, Fusobacterium species, and Peptostreptococcus species. Less common causes include Chlamydia trachomatis and Mycoplasma pneumoniae.

GABHS is the primary organism of concern in most pediatric cases of pharyngitis because appropriate antibiotic therapy is effective and can eliminate complications of rheumatic heart disease. For all cases, including viral etiologies, supportive care is necessary to prevent associated symptoms such as dehydration.

Frequency

United States

Approximately 10% of children seen by medical care providers each year have pharyngitis, and 25-50% of these children have GABHS. Approximately 20% of asymptomatic children are chronic carriers of GABHS.

International

The entire range of pharyngitis-causing pathogens is observed throughout the world. Certain pathogens that are virtually nonexistent in the United States cause pharyngitis in other areas. A good example is diphtheria, which has been nearly eradicated in the United States through immunizations. According to the Red Book, from 1990-1995, approximately 48,000 cases of epidemic diphtheria were reported in the former Soviet Union and central Asia.³ Given the high case-fatality rate of 3-23% and the increased mobility of people, the potential for worldwide spread of diphtheria is a cause for concern. Consider rare or unsuspected causative agents in afflicted individuals who have traveled to high-risk areas or for individuals who have emigrated from these regions, especially in nonimmunized patients.

Race

Prevalence is equal among all races.

Age

Peak prevalence of GABHS pharyngitis is in children aged 5-10 years. In children younger than 2 years, most pharyngitis is of viral etiology, although GABHS is responsible in rare instances. Viral pharyngitis occurs in persons of all ages.

Clinical

History

• Clinical differentiation of the various pathogens of pharyngitis is difficult based on history or physical examination. In 1962, Feinstein et al noted, "The only typical feature of streptococcal infections is the failure to show a single, consistent, typical feature."
• History of exposure to known carriers, fever, headache, and abdominal pain in conjunction with sore throat suggest group A beta-hemolytic streptococci (GABHS) pharyngitis. Involvement of other mucous membranes (eg, conjunctivitis, coryza) suggests a viral etiology.
• Age may also dictate level of concern because GABHS is rarely a true pathogen in children younger than 2 years.
• Because supportive care is a primary goal in all cases, historical information regarding oral intake and hydration status is important.
• Obtain information about previous treatments, treatment failures, and medication allergies.

Physical

• Although no single finding or combination of physical findings distinguishes GABHS from a viral etiology, the following items are suggestive:
  • GABHS pharyngitis is often associated with headache, pharyngeal exudate, painful cervical adenopathy, GI symptoms, chills, and high fever.
  • Viral pharyngitis is usually associated with sneezing, rhinorrhea, and cough. For example, H1N1 influenza can present with sore throat but also has other associated symptoms, such as rhinorrhea and/or cough
  • Mononucleosis is typically exudative with extensive false membranes.
  • Herpangina (usually coxsackievirus A) is associated with papulovesicular lesions of the skin (ie, hand-foot-and-mouth disease).
  • Diphtheria, which is rare in developed countries, is associated with a thick gray membrane that is difficult to remove. It is highly friable and bleeds if manipulated.
• Any one particular sign or symptom, in addition to sore throat, has low specificity in distinguishing GABHS from viral etiologies. Also look for tonsillar asymmetry, which may be a sign of peritonsillar abscesses. This condition can occur in conjunction with soft palate bulging and deviation of the uvula.
• Pay particular attention to signs of dehydration because supportive care is a primary concern and essential regardless of the etiologic agent.

Causes

• Pharyngitis may be bacterial or viral in origin.
• Primary bacterial pathogens account for approximately 30% of cases in children.
• Viruses are isolated in approximately 40% of cases.
• In nearly 30% of cases, no pathogen is isolated.

Differential Diagnoses

Diphtheria
Mononucleosis and Epstein-Barr Virus Infection
Mycoplasma Infections

Other Problems to Be Considered

Coxsackievirus infection

Workup

Laboratory Studies

The following studies are necessary in individuals with suspected pharyngitis:

• Throat culture
  • A throat culture remains the criterion standard for diagnosis, although results can take as long as 48 hours.
  • Throat culture results are highly sensitive and specific for group A beta-hemolytic streptococci (GABHS), but results can vary based on technique, sampling, and culture media.
  • Most institutions and clinics have rapid testing, which is useful when immediate therapy is desired. Rapid testing can be highly reliable when used in conjunction with throat cultures. Several rapid diagnostic tests are available. Such tests are 70-90% sensitive and 95-100% specific compared with throat culture. Rapid screening followed by culture has become the standard in most institutions, especially in developed countries. The somewhat low sensitivity and specificity of clinical screening has led to this approach.
  • The Infectious Diseases Society of America (IDSA) has attempted to categorize some of the clinical differentiators. Although this guide can assist in clinical management, rapid screening followed by culture remains the best combination when resources are available. This clinical decision tool was tested in an emerging health care system and was found to be somewhat helpful in reducing unnecessary antibiotic use in resource-limited settings. Rates of disease outbreaks and availability of laboratory and clinical screening tools can help guide management. The IDSA categorization is as follows:
    • Category 1 (probable viral pharyngitis) - Conjunctivitis, coryza, cough, diarrhea, viral-like exanthems
    • Category 2 (suggestive of possible bacterial pharyngitis) - Fever of more than 38.5°C, tender cervical nodes, headache, petechia of the palate, abdominal pains, or sudden onset (<12 h).
• Testing for viral etiologies
  • If Epstein-Barr virus (EBV) is considered, obtain a CBC count to detect atypical cells in the WBC differential and a Monospot test (or other rapid heterophile antibody test). EBV can also produce a subclinical hepatitis with a slightly elevated aspartate aminotransferase (SGOT)/alanine aminotransferase (SGPT).
  • Monospot findings are often negative in children younger than 6 years with EBV infections and in the first week of symptoms. In adolescents, Monospot testing detects approximately 90% of positive cases ultimately diagnosed with EBV-specific serologies.
  • Other viral etiologies usually do not require further diagnostic testing, but viral cultures can be obtained.
  • During viral outbreaks (eg, H1N1 influenza), if associated symptoms of the outbreak virus may initially include sore throat, one may opt to screen for Streptococcus infection immediately or may screen later, if symptoms persist, in order to rule out Streptococcus as the primary cause of the fever and sore throat.

Imaging Studies

• Imaging studies are usually not necessary unless a retropharyngeal, parapharyngeal, or peritonsillar abscess is suspected. In such cases, a plain lateral neck film can be used as an initial screening tool.

Procedures

• For patients with peritonsillar abscess, needle aspiration and drainage is warranted. Retropharyngeal abscesses often require surgical drainage.
• For patients with signs of dehydration, administer adequate oral or intravenous fluids. Remember that pain may limit oral intake, complicating hydration maintenance in the patient.
• Parents often ask for referrals for tonsillectomy if their child has had multiple episodes of pharyngitis. Inform parents that tonsillectomy offers only temporary relief. A 50-80% reduction in GABHS pharyngitis is noted during the first 2 years following the procedure; however, by the third year after tonsillectomy, no difference is reported compared with control groups.

Treatment

Medical Care

• For patients with viral pharyngitis, care should be supportive, with antipyretics for pain and fever. Ensure proper hydration. Intravenous hydration may be necessary.
• For patients with group A beta-hemolytic streptococci (GABHS), the antibiotic treatment of choice is penicillin. Assuming availability of rapid testing, physicians can decide, based on clinical severity, whether to immediately initiate therapy if a rapid test is positive for GABHS or to delay therapy until culture results are obtained. The issue of early versus delayed therapy has several considerations.⁴
  • Benefits of early treatment include the following:
    • Therapy within 48 hours of symptom appearance appears to shorten duration of symptoms.
    • Early therapy limits spread to other children.
    • Early therapy allows the patient and family to return to their usual routine sooner. More than 80% of patients have culture-negative results after 24 hours of therapy; therefore, the child should remain out of school or daycare for 24 hours after starting therapy.
    • Early therapy limits losses to follow-up.
  • Disadvantages of early treatment 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 may be prevented if antibiotic therapy is initiated within 9 days of symptom onset.⁵
    • Possible drug reactions and expenses may be avoided by not immediately treating cases caused by pathogens other than GABHS (viruses in particular).
• Make decisions on an individual basis depending on available testing, severity of symptoms, availability to arrange follow-up care, and the need for patients and their families to quickly return to their regular routine.
• Some have also suggested that steroid use, dexamethasone (Decadron) in particular, may decrease the pain and symptom duration in those with both viral pharyngitis and streptococcal pharyngitis. This has been primarily shown in the adult population. In children, the length of symptoms has been shown to be minimally improved with adjunct steroid use; however, steroids might be considered in children with significant symptoms or discomfort.⁶

Surgical Care

• An ear, nose, and throat (ENT) specialist or a pediatrician experienced with needle drainage and aspiration can perform the procedure, if warranted by the existence of a peritonsillar abscess.

Consultations

• If the pediatrician is uncomfortable with drainage of a peritonsillar abscess, referral to an ENT specialist or emergency department (ED) physician is warranted.

Diet

• For most patients, no specific diet is needed, but adequate fluid intake and hydration are of vital importance. Monitor the patient to prevent secondary dehydration.

Activity

• To limit the spread to other individuals who have not been exposed, avoid school and new contacts during the initial 24 hours after beginning antibiotic therapy for GABHS.

Medication

Penicillin is the typical therapy for group A beta-hemolytic streptococci (GABHS) pharyngitis, in conjunction with prevention of dehydration and supportive care for pain. Improved compliance with regimens has been noted when penicillin treatment is administered 2-3 times daily, as compared with traditional regimens with 4 daily doses. Administer a minimum of 20 mg/kg/d; larger children are generally administered 500 mg divided into 2 daily doses for 10 days.

Several other medications, including some that are more palatable and meet with better compliance (eg, amoxicillin), have been approved to treat GABHS. Treat relapses or failure to improve with an antibiotic active against beta-lactamase–producing organisms (ie, macrolides, cephalosporins, amoxicillin/clavulanate). The hypothesis is that colonizing pharyngeal bacteria that produce penicillinase have inactivated penicillin, resulting in treatment failure.

Recently, corticosteroids (eg, oral dexamethasone) have been suggested as an adjunctive therapy to decrease pain and length of symptoms in adults with pharyngitis. 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 the time to complete pain relief.⁶ However, for the subset of children with positive rapid streptococcal test results, improvement in the time to onset of pain relief was statistically significant (but marginally clinically significant).

Antibiotics

These agents are used to treat recurrent GABHS pharyngitis.

Amoxicillin (Amoxil, Polymox, Trimox, Pro-Amox, Wymox)

Often used in place of penicillin, but it has not been demonstrated to be more effective. Amoxicillin binds to PBPs, inhibiting bacterial cell wall growth.

Dosing

Adult

250-500 mg PO tid; not to exceed 3 g/d

Pediatric

25-50 mg/kg/d PO divided q8h for 10 d
>2 years: Recent study showed that 750 mg/d PO for 10 d was as effective as 250 mg PO tid

Interactions

Reduces efficacy of PO contraceptives; increased serum concentration with coadministration of probenecid

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 documented hypersensitivity to cephalosporin; caution in renal dysfunction (consider dosage modification), consider consultation with a nephrologist; increased risk of maculopapular rash with EBV, acute lymphocytic leukemia, and CMV

Azithromycin (Zithromax)

Binds to the 50S ribosomal subunit of the bacteria, inhibiting protein synthesis.

Dosing

Adult

500 mg PO on day 1, followed by 250 mg PO on days 2-5

Pediatric

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

Interactions

Limited studies have examined possible interactions; possible interaction with drugs that interact with erythromycin (eg, theophylline, digoxin, anticoagulants); do not administer with antacids

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

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

Precautions

Patients who have an allergic reaction to azithromycin need a longer-than-usual observation period given the medication's long half-life; caution in impaired liver function; possible adverse drug reactions with GI symptoms (eg, diarrhea, abdominal pain, nausea, vomiting)

Benzathine penicillin G (Bicillin L-A)

Has been shown to be effective in more than 90% of cases. Penicillin binds to PBPs, inhibiting bacterial cell wall growth.

Dosing

Adult

1.2 million U IM as a single dose

Pediatric

25,000-50,000 U/kg IM as a single dose; not to exceed 1.2 million U
<27.3 kg: 300,000-600,000 U IM as a single dose
>27.3 kg: 900,000-1,200,000 U IM as a single dose

Interactions

Increased serum concentration with probenecid

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; for deep IM administration only; do not administer IV, SQ, or intra-arterially

Penicillin VK (Pen VK, Pen-Vee K, Veetids)

DOC for patients who can tolerate PO therapy. 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.

Dosing

Adult

250 mg PO tid/qid for 10 d

Pediatric

<27.3 kg: 125 mg PO tid/qid for 10 d
>27.3 kg: Administer as in adults

Interactions

Increased serum concentrations with probenecid

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 cephalosporin allergies and renal impairment; administer 1 h ac or 2 h pc

Erythromycin ethyl succinate (E.E.S, EryPed)

Recommended by the AAP for patients who are allergic to penicillin. Erythromycin binds to the 50S ribosomal subunit of the bacteria, inhibiting protein synthesis.

Dosing

Adult

400-800 mg (as the ethylsuccinate salt) PO qid

Pediatric

40 mg/kg/d PO divided tid/qid for 10 d

Interactions

Potent inhibitor of CYP450 3A4; coadministration may increase toxicity of CYP450 3A4 substrates (eg, theophylline, digoxin, carbamazepine, cyclosporine); may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis; decreases metabolism of repaglinide, thus increasing serum levels and effects

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 hepatic impairment; commonly causes GI symptoms (eg, abdominal pain, diarrhea, nausea, vomiting)

Clindamycin (Cleocin)

Can be used for recurrent GABHS pharyngitis or in carrier-state cases. Inhibits bacterial protein synthesis by its action at the bacterial ribosome. The antibiotic binds preferentially to the 50S ribosomal subunit and affects the process of peptide chain initiation. Some prefer this medication when treating disease related to peritonsillar abscesses that have been drained.

Dosing

Adult

150-300 mg PO tid

Pediatric

30 mg/kg/d PO divided tid for 10 d; not to exceed 1.8 g/d

Interactions

Increased neuromuscular block with coadministration of pancuronium and tubocurarine

Contraindications

Documented hypersensitivity; hepatic impairment prior pseudomembranous colitis

Precautions

Pregnancy

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

Precautions

Renal or hepatic impairment; may cause pseudomembranous colitis; administer cap with full glass of water

Rifampin (Rifadin, Rimactane)

Recommended in conjunction with penicillin for recurrent GABHS and for carrier states. Inhibits RNA synthesis in bacteria by binding to beta subunit of DNA-dependent RNA polymerase, which, in turn, blocks RNA transcription.

Dosing

Adult

10 mg/kg/d PO as a single dose; not to exceed 600 mg/d

Pediatric

Used in conjunction with penicillin VK for 10 d, 20 mg/kg/d PO divided qid for the last 4 d
Alternately, 10 mg/kg PO q12h for 4 d in conjunction with benzathine penicillin

Interactions

Induces microsomal enzymes, which may decrease effects of acetaminophen, PO anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, PO 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 or pyrazinamide may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFT results occur)

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

Hepatic impairment; monitor for any severe flulike symptoms; administer on an empty stomach; may discolor urine, tears, sweat, or other body fluids

Cefuroxime (Ceftin)

Second-generation cephalosporin that maintains gram-positive activity of first-generation cephalosporins; adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis.
Resists degradation by beta-lactamase. Very effective against copathogens. A broad variety of cephalosporins (especially second-generation) have been used; however, their ability to prevent rheumatic heart disease is not known.
The oral susp and tabs are not bioequivalent and require different dosage regimens.

Dosing

Adult

250-500 mg PO bid

Pediatric

Susp: 20 mg/kg/d PO divided bid; not to exceed 500 mg/d
Tab: 125 mg PO bid

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h after administration; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patient receiving potent diuretics (eg, loop diuretics); coadministration with aminoglycosides increases nephrotoxic potential

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

Administer one-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

Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Dosing

Adult

1-2 g/d IM for 10 d

Pediatric

50 mg/kg/d IM for 10 d; not to exceed 1 g/d

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

Caution in breastfeeding women and those who are allergic to penicillin; adjust dose in renal impairment

Cefditoren (Spectracef)

Semisynthetic 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.

Dosing

Adult

200 mg PO bid pc for 10 d

Pediatric

<12 years: Not established
>12 years: Administer as in adults
Severe renal impairment (ie, CrCl <30 mL/min/1.73 m²): Decrease dose to 200 mg PO qd

Interactions

Absorption reduced with H2-receptor antagonists and magnesium and aluminum hydroxide antacids may reduce absorption; probenecid may increase plasma concentrations

Contraindications

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

Precautions

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

Corticosteroids

These agents may be used adjunctively to antibiotics to improve pain relief onset and are especially useful in patients with positive rapid streptococcal antigen test results.

Dexamethasone (Decadron, Dexasone)

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability.
Possesses many pharmacologic benefits but also 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.
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.
For pharyngitis, corticosteroids must be administered in conjunction with antibiotics. Provides symptomatic relief for severe pharyngitis. A one-time IM dose is convenient and avoids compliance issues.

Dosing

Adult

0.75-9 mg/d PO/IM/IV in divided doses q6-12h

Pediatric

0.6 mg/kg PO once; if multiple doses used, not to exceed 10 mg/m²/d divided q6-12h

Interactions

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

Contraindications

Documented hypersensitivity; active bacterial or fungal infection

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

Most adverse effects of corticosteroids are dose-dependent or duration-dependent; 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

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

• For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education articles Sore Throat, Tonsillitis, and Strep Throat.

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.

Multimedia

Media file 1: 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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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

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

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