Bacterial Pharyngitis Treatment & Management

Updated: Feb 08, 2019
  • Author: Joseph Adrian L Buensalido, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Treatment

Approach Considerations

The following are the treatment goals for tonsillopharyngitis: [46]

  • Symptom relief
  • Complication avoidance
  • Decreasing the number of disease-related school or work absences
  • Management expense reduction
  • Quality of life improvement

Conservative treatment is first-line, while surgical management should be performed only if a patient meets recommended indications (see below). [46]

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Medical Care

Overzealous prescription of antibiotics for pharyngitis has been estimated to cost health payers $1.2 billion annually. [53] Therefore, treatment of GABHS pharyngitis should be initiated only after confirmation with a RADT or throat culture. [1] Alternatively, treatment in high-risk patients may be started before throat culture results are available, but antibiotics should be stopped if the culture returns negative results. Even though most cases of GABHS pharyngitis resolve after 3-4 days without treatment, antibiotics decrease the likelihood of local suppurative complications and acute rheumatic fever. Oral antibiotics should be administered for 10 days, although many recent studies show similar efficacy with shorter courses. [54, 55] Antibiotic therapy does not decrease the likelihood of poststreptococcal glomerulonephritis.

Oral penicillin V remains the preferred antibiotic to treat GABHS pharyngitis. [1] Amoxicillin is often prescribed and is an acceptable first-line agent because of its narrow spectrum, the ease of once-daily dosing, and improved palatability, especially for children. Both antibiotics are equally efficacious. [56, 57, 58]

In vitro, no isolate of GABHS has ever been resistant to penicillin. Advantages of oral penicillin include its narrow spectrum, low cost, infrequent adverse effects, and proven track record.

A recent Cochrane meta-analysis evaluating patient outcomes on different antibiotics for group A streptococcal pharyngitis concluded that there is insufficient data to show clinically meaningful differences between antibiotics for GABHS tonsillopharyngitis and that, considering the low cost and absence of resistance, penicillin can still be recommended as first choice. [59] Nevertheless, GABHS is sensitive to many other antibiotics, which can be considered as alternative choices based on numerous factors.

The ACP, American Academy of Pediatrics (AAP), and Infectious Diseases Society of America (IDSA) all agree that the antibiotics of choice for acute pharyngitis are oral penicillin V (for 10 days), intramuscular penicillin G benzathine (single dose), and oral amoxicillin (10 days), which is as efficacious as penicillin but more palatable, especially in children. [48]

Circumstances dictating that a choice other than penicillin V should be used

Compliance: Oral penicillin requires multiple daily doses and a 10-day course. In patients unlikely to adhere to this regimen, one dose of intramuscular benzathine penicillin provides a depot that releases medication over the course. Recent reports have supported the use of once-daily amoxicillin and verified its noninferiority to twice-daily penicillin [56] or twice-daily amoxicillin. [57] Azithromycin, cefdinir, and cefpodoxime may all be given in 5-day courses, although none of these medications should be considered a first-line agent given their extended spectrum and risk for promoting antibiotic resistance. [1, 60, 61] Furthermore, although no differences in treatment outcomes have been found between macrolides and penicillin, children experienced more adverse events with macrolides. [59]

Palatability: Some young children find oral penicillin unpalatable. Taste tests and many doctors’ experiences have shown amoxicillin to be much better tolerated. [62] Amoxicillin’s similar spectrum and low cost make it a reasonable substitute.

Allergy: In patients with an immunoglobulin E (IgE)–mediated penicillin allergy, antibiotics that contain a beta-lactam ring (cephalosporins, amoxicillin) should be used with caution. Although cross-reactivity between penicillin and cephalosporins is probably less than 10%, the risk of anaphylaxis justifies the consideration of other viable agents. [63] In patients with nonanaphylactic reactions to penicillin a first generation cephalosporin (Cephalexin, Cefadroxil) is a treatment alternative. In patients with history of severe or anaphylactic reactions to penicillin, macrolides such as azithromycin, clarithromycin, and erythromycin may be used, although resistance has been reported in the United States [64] and internationally. [65] Clindamycin is also a reasonable alternative in penicillin-allergic patients, as resistance rates remain less than 1% in the United States. [66]

The ACP, AAP, and IDSA all agree that a first-generation cephalosporin (for 10 days) should be prescribed to patients with type IV hypersensitivity to penicillin, while clindamycin (for 10 days), clarithromycin (for 10 days), or azithromycin (for 5 days) should be prescribed to patients with type I hypersensitivity to penicillin. [48] If the patient is allergic or has some form of incompatibility to penicillin, the European Archives of Otorhinolaryngology clinical practice guidelines also suggest cephalosporins or macrolides as alternatives. [46]

Recurrence: Test of cure is not indicated when pharyngitis symptoms have resolved following treatment. In patients with recurrent symptoms, retreatment with an initial first-line agent (oral penicillin, benzathine penicillin, or a first-generation cephalosporin) is reasonable. Worth noting is the difficulty in differentiating between viral pharyngitis with GABHS carriage and actual GABHS pharyngitis. This becomes even more of an issue in patients with multiple recurrences. Between 5% and 15% of children are asymptomatic carriers during seasons when GABHS pharyngitis is most prevalent. [67] A positive test result during a time of wellness may indicate GABHS carriage. When multiple recurrences are believed to be due to GABHS infection, clindamycin or amoxicillin/clavulanic acid is indicated. [1] A 2018 systematic review supports this recommendation because of the superiority of the two drugs to penicillin in terms of eradicating streptococci and nonstreptococci. However, the level of evidence was deemed of moderate quality owing to the risk of bias from two included randomized controlled trials. [68]

The European Archives of Otorhinolaryngology clinical practice guidelines also recommend oral penicillin as first-line therapy for beta-hemolytic streptococci. Oral cephalosporins (eg, cefadroxil, cephalexin) are the recommended alternatives that can be used for penicillin failure, frequent recurrences, or whenever a more reliable eradication of beta-hemolytic streptococci is needed. [46]

Pharyngeal carriage

Antimicrobial therapy is not indicated for most pharyngeal GAS carriers. Eradication for carriage may be indicated in the following situations:

  • Local outbreak of acute rheumatic fever (ARF) or poststreptococcal glomerulonephritis
  • Outbreak of GAS pharyngitis in a closed or semi-closed community
  • Family history of ARF
  • Multiple ("ping-pong") episodes of documented symptomatic GAS pharyngitis occurring within a family for many weeks despite appropriate therapy

Antimicrobial treatment options that have been shown to be more effective than penicillin monotherapy include clindamycin, cephalosporins, amoxicillin/clavulanic acid, azithromycin, or a combination that includes either penicillin V or G with rifampin for the last 4 days of treatment. [69]

Delayed antibiotic prescribing

When a patient presents with signs and symptoms that cannot be initially confirmed as viral or bacterial by a healthcare provider, one strategy is to provide a delayed antibiotic prescription. The delayed prescription can be filled by the patient "just in case" the sore throat does not follow the course of viral pharyngitis, instead progressing as bacterial pharyngitis. Symptom control was similar between immediate and delayed antibiotic prescription, with the latter having the potential to decrease antibiotic usage. [70]

Corticosteroids

A double-blind, placebo-controlled randomized trial conducted in 42 family practices in South and West England enrolled 576 patients who presented with acute sore throat that was deemed to not require immediate antibiotic therapy. Administration of a single 10-mg dose of oral dexamethasone significantly increased the proportion of patients with resolution of symptoms at 48 hours compared with placebo, although not at 24 hours. [71]

Nonetheless, the authors stressed that the results did not suggest that all patients presenting with sore throat should receive a corticosteroid. In fact, the question was raised: "Is it worth using corticosteroids to treat a relatively harmless disorder?" particularly since a cohort study of more than 1.5 million patients showed that the risks for fractures, venous thromboembolism, and sepsis were significantly higher in those given steroids within 30 days and despite low doses prescribed. [72, 73]

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Surgical Care

In rare cases, pharyngitis spreads to adjacent structures and forms abscesses. In these cases, a drainage procedure performed by an interventional radiologist or otolaryngologist should be considered.

Tonsillectomy is one of the most frequently performed procedures in the United States [68] and United Kingdom. [74] However, the IDSA does not recommend tonsillectomy if it will be performed solely to reduce the frequency of GAS pharyngitis. [1] A systematic review showed that tonsillectomy may reduce sore throat frequency in children and adults compared with no surgery but is associated with more morbidity. [74]

Clinical practice guidelines published in the European Archives of Otorhinolaryngology state that surgical options can be either intracapsular or extracapsular tonsil surgery and can be used for the following: [75]

  • Recurrent acute tonsillitis
  • Peritonsillar abscess
  • Infectious mononucleosis

Of course, conservative treatment should be first-line. However, the recommendation to use of tonsillectomy for recurrent tonsillitis in children is based on moderate quality of evidence, while the evidence in adults is of low quality. Tonsillectomy in children modestly affects the number of sore throat episodes per year. Data in adults were found to be heterogenous, explaining why tonsillectomy cannot be considered effective yet in these patients. In fact, additional research is still needed to show if tonsillectomy has significant benefit over the nonsurgical treatment of tonsillitis or tonsillopharyngitis. [75]

In general, tonsillectomy positively affects quality of life, although additional research may better establish this. Conversely, tonsillotomy and similar procedures are associated with much less postoperative pain and bleeding and similar outcomes in the children and young adults. However, the Brodsky scale should be used to evaluate the patient’s tonsil volume; a grade of more than 1 indicates eligibility for tonsillotomy. [75]

The number of tonsillitis episodes in the preceding 12 months determines the indication to perform tonsillectomy or tonsillotomy. Surgery is not recommended in patients with less than 3 episodes, which means watchful waiting for 6 months is reasonable. However, a patient who has had 6 or more episodes of tonsillitis in the preceding 12 months is considered a candidate for tonsil surgery. [75]

In patients with peritonsillar abscess, the following are effective treatment methods: [75]

  • Needle aspiration
  • Incision and drainage
  • Abscess tonsillectomy

Before deciding which surgical method is to be performed, patient compliance and ability to cooperate must be considered. It is also recommended to prescribe antibiotic therapy simultaneously, although additional research on this subject is still being conducted. [75]

Tonsillectomy of the contralateral side should be performed only in patients who meet criteria for elective tonsillectomy or if the peritonsillar abscess is bilateral. [75]

Needle aspiration or incision and drainage is preferred if the patient has comorbidities, increased surgical risk, or a coagulation disorder. [75]

Patients with infectious mononucleosis (viral rather than bacterial pharyngitis) should not undergo routine tonsillectomy for symptom control. Tonsillectomy becomes indicated if clinically significant upper airway obstruction results from inflammatory tonsillar hyperplasia. If the patient has no signs of a concomitant bacterial infection, antibiotics should not be prescribed. In contrast, a steroid may be prescribed to relieve symptoms in patients with infectious mononucleosis.

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Consultations

An otolaryngologist should be consulted for local suppurative complications such as peritonsillar abscess and mastoiditis. Tonsillectomy may be considered in recurrent GABHS infection. [76, 77]

An infectious diseases expert may be consulted for patients with immunocompromising conditions or when an agent other than GABHS (eg, HIV) is suspected or confirmed.

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Diet

Allow a regular diet as tolerated in patients with bacterial pharyngitis. Warm liquids may provide symptomatic relief.

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Activity

Encourage rest during the acute illness.

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Prevention

Patients with bacterial pharyngitis should be kept out of daycare, school, or work until 24 hours after the initiation of antibiotics.

Vaccination

Despite the massive disease burden caused by S pyogenes (GAS) infection, no licensed vaccine is available to prevent GAS infection and its complications, particularly rheumatic fever and rheumatic heart disease. [78, 79, 80]

GAS vaccines can be classified into two groups: M-protein–based and non–M-protein–based vaccines. The vaccines undergoing clinical investigation are the N-terminal M-protein–based 26- and 30-valent vaccines and the conserved M-protein vaccines, J8 and StreptInCor vaccines. [78, 79]

GAS vaccines are considered "impeded vaccines" for multiple reasons, including the following: [78, 79]

  • Safety reasons (the vaccine antigens may contain autoimmune epitopes that could increase the risk of rheumatic fever in recipients)
  • The complexity of the epidemiology of S pyogenes infection (numerous emm types, anatomic location of disease, geographic differences)
  • Insufficient return of investment by vaccine manufacturers, as most serious GAS diseases occur in low- and middle-income countries
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Further Inpatient Care

Droplet precautions should be observed until 24 hours after the initiation of antibiotics.

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