Prehospital Care

See the list below:

Prehospital care usually is not necessary for uncomplicated pharyngitis unless airway compromise is an issue.
Intubation should not be attempted unless the patient stops breathing spontaneously.

Emergency Department Care

See the list below:

Assess and secure the airway, if necessary.
Assess the patient for signs of toxicity, epiglottitis, or oropharyngeal abscess.^[31]
Evaluate the hydration status because severe pharyngitis limits oral intake. Appropriate measures to rehydrate should be initiated, including intravenous hydration.
Assess for GAS infection if clinically suspected. A suggested algorithm as is follows.
- In general, patients should not be treated without a positive culture or positive rapid antigen detection test result because of increasing antibiotic resistance. Guidelines from the Infectious Diseases Society of America (IDSA) and American Heart Association state that microbiologic confirmation (via a rapid antigen test or culture) is required for the diagnosis of GAS.^{[13, 7]}
- Perform rapid antigen detection test if GAS is clinically suspected based on history and physical examination. If positive, begin antibiotic therapy. Testing does not usually need to be performed on patients with acute pharyngitis whose clinical and epidemiologic features do not suggest GAS as the etiology (Centor score 0-1).
- Patients who are positive for all 4 Centor criteria can often be treated with antibiotics without antigen testing or cultures if rapid antigen testing is not available.
- It is important to note that the Centor criteria can be used to identify cases of pharyngitis that are likely viral (score 0-1) and do not need antigen testing. Patients with a Centor score of 4 should have confirmation of GAS infection with an antigen test before being treated with antibiotics, unless such testing is unavailable.
- Household contacts of patients with GAS infection or scarlet fever should be treated for a full 10 days of antibiotics without testing only if they have symptoms consistent with GAS.^[7]Asymptomatic contacts should not be treated.
- If clinically doubtful or the above criteria are not met, it is best to await rapid antigen or culture results to initiate antibiotic therapy.

A study by Cohen et al suggested that rules-based selective testing strategies for children with pharyngitis do not have a sufficient combination of sensitivity and specificity to determine which patients should be tested for group A streptococcal infection. Using an external validation cohort of 676 children, the investigators determined that none of the clinical prediction rules used in the study reached the investigators’ diagnostic accuracy target; specifically, a sensitivity and specificity of greater than 85%.^[32]

Consultations

With a few exceptions, uncomplicated cases of pharyngitis should not require a consultation. Infectious disease specialists should be consulted in the case of unusual presentation or in the case of a patient who is immunocompromised.

Guidelines

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Media Gallery

Streptococcus pyogenes at 100X magnification.
Rapid antigen detection test for group A beta-hemolytic streptococci.
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.

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Author

John R Acerra, MD Associate Professor, Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Director, Global Emergency Medicine Program, LIJ Medical Center and North Shore University Hospital, Northwell Health System

John R Acerra, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician / Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Prisma Health Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

Acknowledgements

Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center

Disclosure: Nothing to disclose.