eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease
Pharyngitis: Treatment & Medication
Updated: Oct 21, 2009
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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).
- Benefits of early treatment include the following:
- 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.
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
Reduces efficacy of PO contraceptives; increased serum concentration with coadministration of probenecid
Documented hypersensitivity
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.
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
Limited studies have examined possible interactions; possible interaction with drugs that interact with erythromycin (eg, theophylline, digoxin, anticoagulants); do not administer with antacids
Documented hypersensitivity
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.
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
Increased serum concentration with probenecid
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; 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.
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
Increased serum concentrations with probenecid
Documented hypersensitivity
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.
Adult
400-800 mg (as the ethylsuccinate salt) PO qid
Pediatric
40 mg/kg/d PO divided tid/qid for 10 d
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
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 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.
Adult
150-300 mg PO tid
Pediatric
30 mg/kg/d PO divided tid for 10 d; not to exceed 1.8 g/d
Increased neuromuscular block with coadministration of pancuronium and tubocurarine
Documented hypersensitivity; hepatic impairment prior pseudomembranous colitis
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.
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
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)
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
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.
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
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
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
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.
Adult
1-2 g/d IM for 10 d
Pediatric
50 mg/kg/d IM for 10 d; not to exceed 1 g/d
Probenecid may increase ceftriaxone levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides 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
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.
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
Absorption reduced with H2-receptor antagonists and magnesium and aluminum hydroxide antacids may reduce absorption; probenecid may increase plasma concentrations
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
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.
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
Effects decrease with coadministration of barbiturates, phenytoin, and rifampin; 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
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
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| Overview: Pharyngitis |
| Differential Diagnoses & Workup: Pharyngitis |
 Treatment & Medication: Pharyngitis |
| Follow-up: Pharyngitis |
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References
[Guideline] Michigan Quality Improvement Consortium. Acute pharyngitis in children. Southfield (MI): Michigan Quality Improvement Consortium; 2009 Jan. [Full Text].
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].
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.
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].
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].
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].
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].
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].
Edress D. Dosing Handbook. 4th ed. Egleston Scottish Rite Children's Healthcare System; 1999-2000.
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].
Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].
Gerber MA, Markowitz M. Management of streptococcal pharyngitis reconsidered. Pediatr Infect Dis. Sep-Oct 1985;4(5):518-26. [Medline].
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].
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].
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 inthe emergency department. Ann Emerg Med. Apr 2001;37(4):377-81. [Medline].
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].
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].
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].
Further Reading
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
