Download Evidence-Based Evaluation And Management Of Patients With

Evidence-Based Evaluation And
Management Of Patients With
Pharyngitis In The Emergency
Department
September 2015
Volume 17, Number 9
Authors
Amy F. Hildreth, MD
Department of Emergency Medicine, Brigham and Women's Hospital,
Boston, MA
Sukhjit Takhar, MD, MS
Attending Physician, Department of Emergency Medicine, Brigham and
Women's Hospital, Instructor of Emergency Medicine, Harvard Medical
School, Boston, MA
Abstract
Pharyngitis is a common presentation, but it can also be associated with life-threatening processes, including sepsis and airway compromise. Other conditions, such as thyroid disease and
cardiac disease, may mimic pharyngitis. The emergency clinician
must sort through the broad differential for this complaint using
a systematic approach that protects against early closure of the
diagnosis. This issue reviews the various international guidelines
for pharyngitis and notes controversies in diagnostic and treatment strategies, specifically for management of suspected bacterial, viral, and fungal etiology. A management algorithm is presented, with recommendations based on a review of the best available
evidence, taking into account patient comfort and outcomes, the
need to reduce bacterial resistance, and costs.
Peer Reviewers
Mark Andrew Clark, MD
Assistant Professor of Emergency Medicine, Program Director,
Emergency Medicine Residency, Mount Sinai St. Luke’s, Mount Sinai
Roosevelt, Icahn School of Medicine at Mount Sinai, New York, NY
Benjamin Hatten, MD, MPH
Assistant Professor, Department of Emergency Medicine, University of
Colorado School of Medicine, Aurora, CO
CME Objectives
Upon completion of this article you should be able to:
1.
Identify and describe life-threatening causes of pharyngitis.
2.
Identify the difference between viral and bacterial etiologies of
pharyngitis.
3.
Understand the controversy in diagnosing and treating group A
hemolytic Streptococcus pharyngitis.
Prior to beginning this activity, see “Physician CME Information”
on the back page.
Editor-In-Chief
Andy Jagoda, MD, FACEP
Professor and Chair, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, Medical
Director, Mount Sinai Hospital, New
York, NY
Associate Editor-In-Chief
Kaushal Shah, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
Editorial Board
William J. Brady, MD
Professor of Emergency Medicine
and Medicine, Chair, Medical
Emergency Response Committee,
Medical Director, Emergency
Management, University of Virginia
Medical Center, Charlottesville, VA
Calvin A. Brown III, MD
Director of Physician Compliance
Compliance,,
Credentialing and Urgent Care
Services, Department of Emergency
Medicine, Brigham and Women's
Hospital, Boston, MA
Mark Andrew Clark, MD
Assistant Professor of Emergency
Medicine, Program Director,
Emergency Medicine Residency,
Mount Sinai St. Luke's, Mount Sinai
Roosevelt, New York, NY
Peter DeBlieux, MD
Professor of Clinical Medicine,
Interim Public Hospital Director
of Emergency Medicine Services,
Louisiana State University Health
Science Center, New Orleans, LA
Nicholas Genes, MD, PhD
Assistant Professor, Department of
Emergency Medicine, Icahn School
of Medicine at Mount Sinai, New
York, NY
of Pittsburgh Medical Center,
Pittsburgh, PA
of Emergency Medicine, Vanderbilt
University Medical Center, Nashville, TN
Research Editor
Andrea Duca, MD
Charles V. Pollack Jr., MA, MD,
Emergency Medicine Residency,
Stephen H. Thomas, MD, MPH
FACEP
Università Vita-Salute San Raffaele
George Kaiser Family Foundation
Professor and Chair, Department of
of Milan, Italy
Professor & Chair, Department of
Emergency Medicine, Pennsylvania
Michael A. Gibbs, MD, FACEP
Emergency Medicine, University of
Hospital, Perelman School of
Professor and Chair, Department
Oklahoma School of Community
International Editors
Medicine, University of Pennsylvania,
of Emergency Medicine, Carolinas
Medicine, Tulsa, OK
Peter Cameron, MD
Philadelphia, PA
Medical Center, University of North
Academic Director, The Alfred
David M. Walker, MD, FACEP, FAAP
Carolina School of Medicine, Chapel Michael S. Radeos, MD, MPH
Emergency and Trauma Centre,
Director, Pediatric Emergency
Hill, NC
Assistant Professor of Emergency
Monash University, Melbourne,
Services, Division Chief, Pediatric
Medicine, Weill Medical College
Australia
Steven A. Godwin, MD, FACEP
Emergency Medicine, Elmhurst
of Cornell University, New York;
Professor and Chair, Department
Hospital Center, New York, NY
Giorgio
Carbone, MD
Research Director, Department of
of Emergency Medicine, Assistant
Chief, Department of Emergency
Ron M. Walls, MD
Emergency Medicine, New York
Dean, Simulation Education,
Medicine Ospedale Gradenigo,
Professor and Chair, Department of
Hospital Queens, Flushing, NY
University of Florida COMTorino, Italy
Emergency Medicine, Brigham and
Jacksonville, Jacksonville, FL
Ali S. Raja, MD, MBA, MPH
Women's Hospital, Harvard Medical Amin Antoine Kazzi, MD, FAAEM
Vice-Chair, Emergency Medicine,
Gregory L. Henry, MD, FACEP
School, Boston, MA
Associate Professor and Vice Chair,
Massachusetts General Hospital,
Clinical Professor, Department of
Department of Emergency Medicine,
Boston, MA
Emergency Medicine, University
Critical Care Editors
University of California, Irvine;
of Michigan Medical School; CEO,
Robert L. Rogers, MD, FACEP,
American University, Beirut, Lebanon
William
A.
Knight
IV,
MD,
FACEP
Medical Practice Risk Assessment,
FAAEM, FACP
Associate Professor of Emergency
Inc., Ann Arbor, MI
Hugo Peralta, MD
Assistant Professor of Emergency
Medicine and Neurosurgery, Medical
Chair of Emergency Services,
Medicine, The University of
John M. Howell, MD, FACEP
Director, EM Midlevel Provider
Hospital Italiano, Buenos Aires,
Maryland School of Medicine,
Clinical Professor of Emergency
Program, Associate Medical Director,
Argentina
Baltimore, MD
Medicine, George Washington
Neuroscience ICU, University of
University, Washington, DC; Director Alfred Sacchetti, MD, FACEP
Dhanadol Rojanasarntikul, MD
Cincinnati, Cincinnati, OH
of Academic Affairs, Best Practices,
Attending Physician, Emergency
Assistant Clinical Professor,
Scott D. Weingart, MD, FCCM
Inc, Inova Fairfax Hospital, Falls
Medicine, King Chulalongkorn
Department of Emergency Medicine,
Associate
Professor
of
Emergency
Church, VA
Memorial Hospital, Thai Red Cross,
Thomas Jefferson University,
Medicine, Director, Division of ED
Thailand; Faculty of Medicine,
Philadelphia, PA
Shkelzen Hoxhaj, MD, MPH, MBA
Critical Care, Icahn School of Medicine
Chulalongkorn University, Thailand
Chief of Emergency Medicine, Baylor Robert Schiller, MD
at Mount Sinai, New York, NY
College of Medicine, Houston, TX
Suzanne Y.G. Peeters, MD
Chair, Department of Family Medicine,
Emergency Medicine Residency
Senior Research Editors
Beth Israel Medical Center; Senior
Eric Legome, MD
Director, Haga Teaching Hospital,
Faculty, Family Medicine and
Chief of Emergency Medicine,
James Damilini, PharmD, BCPS
The Hague, The Netherlands
Community Health, Icahn School of
King’s County Hospital; Professor of
Clinical Pharmacist, Emergency
Medicine at Mount Sinai, New York, NY
Clinical Emergency Medicine, SUNY
Room, St. Joseph’s Hospital and
Downstate College of Medicine,
Scott Silvers, MD, FACEP
Medical Center, Phoenix, AZ
Brooklyn, NY
Chair, Department of Emergency
Joseph D. Toscano, MD
Medicine, Mayo Clinic, Jacksonville, FL
Keith A. Marill, MD
Chairman, Department of Emergency
Research Faculty, Department of
Medicine, San Ramon Regional
Corey M. Slovis, MD, FACP, FACEP
Emergency Medicine, University
Medical Center, San Ramon, CA
Professor and Chair, Department
Case Presentations
fever are thought to have been reduced by antibiotic use, and they remain a primary consideration
for diagnosis and treatment.10 However, as the incidence of acute rheumatic fever has declined greatly
in the United States and other developed countries,
the importance of treatment to prevent this complication has come into question.11
This leads to many questions that the emergency
clinician must be able to answer, including: Does this
patient have strep throat? Are antibiotics needed?
What else, if anything, can we use to treat pain? Supplemental questions to those basics include: Could
this be something dangerous, such as epiglottitis or
a deep neck space infection? Are there other pathogens such as group C Streptococcus or Fusobacterium
spp that we should be treating with antibiotics?12
While many guidelines exist, including the
Infectious Diseases Society of America (IDSA)
guidelines from 2012, the European Society of
Clinical Microbiology and Infectious Diseases (ESCMID) guideline from 2012, the American Heart
Association/American Academy of Pediatrics
(AHA/AAP) guideline, and the Centers for Disease Control and Prevention/American Academy
of Family Physicians/American College of Physicians (CDC/AAFP/ACP) guideline from 2001, the
recommendations conflict, causing confusion about
best practices, and this contributes to broad practice variability.13 This issue of Emergency Medicine
Practice provides a systematic review of the literature in order to provide clarity for best practice.
You are working in a community emergency department
when a first-time mother brings in her two-and-a-halfyear-old daughter who has had a sore throat for 2 days.
She has had low-grade fevers and will not eat, complaining of pain. She is not in daycare, looks well overall, and
is drinking from a juice box in the examination room.
Mom is asking for antibiotics for strep throat and you
think to yourself, “Is this an appropriate patient to give
antibiotics to?”
The next patient you see is a 20-year-old man who
has had a sore throat for 2 days. He is febrile to 38.8°C,
has bilateral tonsillar erythema and exudates, and tender
cervical adenopathy. He has not been coughing, is able to
eat and drink, and does not have any trouble breathing,
but he is asking for pain medication. What should you
give him? Does he need a test for strep? If so, which one?
Does he need antibiotics? If so, what kind?
Later that day, you see a 35-year-old woman with 5
days of sore throat, presenting with voice changes. She
looks well, but she but swears her voice is not normally this
hoarse, and she has odynophagia without any other associated symptoms. Could this be a life-threatening cause of
sore throat? Does she need an urgent intervention?
Your last patient is a 65-year-old male smoker complaining of several weeks of sore throat and hoarseness. He
has not had a fever or other upper respiratory symptoms.
He does not have any known exposures, and reports a gradual worsening of symptoms. You think to yourself, “What
is the chance this is not infectious?” What other etiologies
should you consider in this patient with sore throat?
Critical Appraisal Of The Literature
Introduction
A literature search was performed on PubMed using
the search terms: pharyngitis, tonsillitis, pharyngotonsillitis, streptococcal pharyngitis, and acute rheumatic
fever. Titles, abstracts, and full articles were reviewed
for content. The National Guideline Clearinghouse
(www.guideline.gov) was also searched using the
terms pharyngitis and sore throat and, within the
practice guidelines, primary sources of literature
were reviewed. The Cochrane Database of Systematic Reviews was also referenced using the terms
pharyngitis and sore throat. Excluded articles included
those regarding sore throat secondary to intubation.
Important practice guidelines reviewed included
the IDSA publication on streptococcal pharyngitis,
the AHA/AAP publication on rheumatic fever and
streptococcal pharyngitis, the ESCMID publication
of acute sore throat, and the CDC/AAFP/ACP combined practice guideline on principles for appropriate antibiotic use in acute pharyngitis in adults.
These guidelines attempt to be evidence-based, but
they fall to consensus for deciding which patients to
test and treat (arguably their most important sections),
which leads to discrepancies between them. While the
literature is rich in studies on group A Streptococcus,
Pharyngitis is the combination of sore throat, fever,
and pharyngeal inflammation,1 and it is one of the
most common chief complaints seen in the emergency department (ED). Sore throat accounted for
over 2 million ED visits in 2007.2 Emergency clinicians must be able to assess these patients for airway
threats and determine an efficient treatment strategy.
This simple presentation is still the cause of
much debate and practice variation, with conflicting guidelines for care. The crux of the pharyngitis
debate centers around group A beta hemolytic
Streptococcus (GABHS), or “strep throat,” which
accounts for 20% to 30% of sore throat visits in
children3,4 and 5% to 15% of sore throat visits in
adults.5 It is estimated that, in the United States,
between $224 million and $539 million are spent
annually on GABHS in children and adolescents,6
not including the costs for the adult cases. This
infection has been known to cause both suppurative complications (eg, peritonsillar abscess or otitis
media) and systemic complications (eg, acute rheumatic fever or glomerulonephritis).7-9 The incidence
of suppurative complications and acute rheumatic
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Differential Diagnosis
rapid antigen detection tests (RADTs), and different
treatments for pharyngitis, data are lacking on acute
rheumatic fever in the developed world, as its prevalence has sharply declined. Data on other causes of
bacterial pharyngitis (eg, groups C and G Streptococcus and Fusobacterium spp) are also limited, as they
have been thought to be inconsequential. Recent
data on suppurative complications from GABHS are
also lacking, as most of the data come from studies
done prior to 1975, and it is unknown how these
results apply to current conditions.
Many common pathogens can cause sore throat.
Life-threatening, airway-compromising etiologies
for sore throat must be ruled out, including epiglottitis, uvulitis, deep space neck infections (eg, peritonsillar abscess or retropharyngeal abscess), Ludwig
angina, and uncommon etiologies like diphtheria.
Drooling, voice change, stridor, trismus, and/or
a toxic appearance are red flags of a more serious
disease state.15
The most common cause of pharyngitis is viral
syndromes,3,5 but GABHS is responsible for 20%
to 30% of sore throat visits in children3,4 and 5%
to 15% of sore throat visits in adults.5 Other bacterial causes of pharyngitis are groups B, C, and G
beta hemolytic streptococci.24-28 Acute rheumatic
fever has not been described as a complication of
these pathogens.10 A 2006 review of 128 cases of
peritonsillar abscess in Northern Ireland showed 7
of these cases had cultures that grew group B or C
streptococci.29 Several studies have reported isolation of Fusobacterium from throat swabs, suggesting
that this bacterium may be a cause for recurrent or
persistent pharyngitis.18,30-35 However, the IDSA
guidelines report that the evidence to support this
is weak.10 The CDC/AAFP/ACP guideline also
reports that antibiotic treatment is necessary only
for those patients with GABHS infection.36
The emergency clinician should remember that
acute pharyngitis has a typical duration of 3 to 5
days. If symptoms persist longer than this typical
period, then the differential should be broadened
to include life-threatening complications (Lemierre
syndrome, abscesses, etc).34
Also included in the differential are causes for
sore throat that are not infectious, including systemic causes (Kawasaki disease, Stevens-Johnson
syndrome, thyroiditis, neutropenia), trauma
(foreign body, penetrating injury, caustic exposure,
chemical or thermal burn, retropharyngeal hematoma), malignancy, and inflammatory processes such
as allergies, gastroesophageal reflux, or postnasal
drip. These causes should not be forgotten in a
patient with isolated sore throat without fever or
other infectious symptoms.
Etiology And Pathophysiology
The complex oral cavity and pharynx have many
different structures that are vulnerable to inflammation that can cause pain. (See Figure 1.) This
inflammation is caused primarily by infection of the
lining of the posterior oral pharynx. The emergency
clinician must be able to locate the specific area and
the extent of inflammation to help determine the
possible risks and etiologies.
Pharyngitis is most commonly due to viral
causes,3,5 but it can also be caused by bacterial or,
rarely, fungal pathogens. Table 1 (see page 4) summarizes many of the most common etiologic agents.
GABHS is most common during late winter and early
spring in temperate climates, and it is transmitted
via respiratory secretions.14 It most commonly affects
children and adolescents aged 5 to 15 years.15
Figure 1. Oral Cavity And Pharynx Anatomy
Prehospital Care
The primary goal of prehospital management
of patients with pharyngitis is rapid recognition
of airway compromise, with secondary goals of
comfort and pain relief. When caring for a patient
at risk for airway compromise, the receiving facility
should be alerted as soon as possible to prepare
for an emergent airway. The prehospital provider
should focus on assessing vital signs (most importantly, oxygenation and respiratory rate); monitor-
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Table 1. Infectious Causes For Sore Throat16
Clinical Description
Causes
Clinical Features
Infectious pharyngitis
•
•
•
•
•
•
•
•
Sore throat, odynophagia, dysphagia, erythematous tonsils, tonsillar
exudate
Mononucleosis
• Epstein-Barr virus
• Cytomegalovirus
Fatigue, malaise, sore throat, fever, adenopathy, enlarged tonsils, rash,
splenomegaly
Common cold
• Rhinovirus
• Coronavirus
• Parainfluenza virus
Cough, coryza, sore or scratchy throat, headache, muscle aches
Diphtheria
• Corynebacterium diphtheriae
Stridor, drooling, fever, hoarseness, odynophagia, sore throat, pseudomembrane on pharynx or tonsils
Influenza
• Influenza A and B virus
Fever, cough, sore throat, coryza, muscle aches, headache, fatigue,
vomiting, diarrhea
Pharyngo-conjunctival fever
• Adenovirus
Cough, coryza, sore throat, bronchitis, diarrhea, conjunctivitis, fever,
gastroenteritis
Lemierre syndrome
• Fusobacterium spp
• GABHS
• Other anaerobes17
Septic thrombophlebitis of the internal jugular vein and septic emboli of
distant sites after acute sore throat18
Vincent angina
• Mixed anaerobes
• Fusiform bacilli
• Spirochetes
Acute necrotizing infection of the pharynx, unilateral sore throat, bad
taste in mouth, and foul breath. Deep, well-circumscribed ulcer of 1
tonsil
Oropharyngeal tularemia
• Francisella tularensis
Fever, sore throat, mouth ulcers, vomiting, diarrhea
Secondary syphilis
• Treponema pallidum
Nonitchy rash that involves hands and feet, sore throat, fever, lymphadenopathy, fatigue, muscle aches
Herpangina
• Coxsackievirus A
Hand, foot, and mouth disease
Primary HIV infection
• Human immunodeficiency virus
Fever, rash, headache, malaise, muscle aches, oral ulcers, sore throat,
night sweats, weight loss, adenopathy
Epiglottitis
•
•
•
•
•
Fever, odynophagia, dysphagia, drooling, stridor, respiratory distress,
tripod positioning19
Uvulitis
• Haemophilus influenzae
• GABHS20
Dysphagia, foreign body sensation, drooling, stridor, muffled or “hot
potato” voice19
•
•
•
•
•
•
GABHS
Staphylococcus aureus
Haemophilus influenzae
Fusobacterium
Prevotella
Peptostreptococcus spp21
Fever, neck pain, decreased range of motion of neck, palpable neck
mass, trismus, respiratory distress31
•
•
•
•
Streptococcus
Staphylococcus
Fusobacterium
Bacteroides spp23
Fever, pain in associated teeth, “woody” induration of the floor of the
mouth, drooling, trismus, dysphagia, stridor
Infectious Causes
Streptococcus group A, C, G
Neisseria gonorrhoeae
Arcanobacterium haemolyticum
Yersinia enterocolitica
Herpes simplex virus 1 and 2
Mycobacterium pneumoniae
Chlamydophila pneumoniae
Fusobacterium spp
Haemophilus influenzae
Haemophilus parainfluenzae
Streptococcus pneumoniae
GABHS
Staphylococcus aureus
Abscesses
Retropharyngeal,
parapharyngeal space
infection
Peritonsillar abscess
Submandibular abscess
(Ludwig angina)
Fever, odynophagia, uvular deviation, trismus, muffled or “hot potato”
voice19,22
Abbreviation: GABHS, group A beta hemolytic Streptococcus; HIV, human immunodeficiency virus.
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ing for voice change, drooling, or other evidence
of airway collapse; attempting to keep the patient
calm and comfortable; and transporting the patient
to the hospital.
the tongue to rule out Ludwig angina (submandibular abscess).
The neck is carefully examined for adenopathy,
masses, and range of motion. A thyroid examination
may assess for evidence of thyroiditis, which may
present as sore throat. Anterior cervical adenopathy
is often associated with GABHS, while posterior
cervical adenopathy in a patient aged < 30 years is
suggestive of mononucleosis.
Finally, a skin inspection is performed. GABHS
and other streptococcal illness can be associated with
a diffuse, erythematous exanthem that feels like sandpaper, in which case, a diagnosis of scarlet fever is
made.45 Arcanobacterium haemolyticum can also cause a
scarlatiniform maculopapular rash,46 and mononucleosis can cause a maculopapular exanthem.19
Emergency Department Evaluation
In most cases of pharyngitis, once it is determined
that the patient is not in respiratory distress and
does not appear toxic, the emergency clinician can
move quickly to a detailed history and physical examination. The physical examination is not enough
to distinguish viral pharyngitis from GABHS,37-42
but certain aspects can help.
History
The history focuses on detailing infectious symptoms and exposures, especially close contacts with
GABHS infections in the previous 2 weeks.43 Patients with GABHS typically have a more suddenonset sore throat, dysphagia, fever, pharyngeal
exudates and/or erythema, and tender and enlarged
anterior cervical lymph nodes.44 In viral pharyngitis, patients are more likely to have other associated
symptoms, such as conjunctivitis, coryza, hoarseness, cough, diarrhea and/or typical exanthems.
These symptoms should be asked about, along with
the duration of symptoms, onset, and course.
Other important historical data to determine
include the use of antipyretics or analgesics, trauma,
ingestions, and immunization history. Sexual history is also helpful when considering less-common
causes of pharyngitis, such as gonorrhea. Any recent
dental procedures or infections should be recorded,
especially if a patient is immunocompromised, as
this could place the patient at risk for a life-threatening complication, such as Ludwig angina. It should
be noted if there is a history of rheumatic fever, as
a recurrent streptococcal infection could be more
dangerous in this patient population.
The emergency clinician should ask about smoking, alcohol use, and weight loss, especially in older
patients with isolated sore throat for which there is a
concern for malignancy.
The Centor Criteria
The Centor criteria were developed in 1981 from a
sample of 286 adult ED patients,40,47 based on the 4
findings of the history and physical examination that
were most likely to be seen in patients with GABHS
infection. The score was adapted by McIsaac in 1998
in 521 patients, with the addition of an age qualifier
(+1 for ages 3-14 years, 0 for ages 15-44 years, -1 if
age ≥ 45 years), where the authors found it was more
sensitive than clinical gestalt in diagnosing GABHS.48 (See Table 2.) In 2000, McIsaac validated the
score in 619 patients in an ambulatory care setting,49
and in 2004 on another 787 patients.50 The Centor
score, with or without the modification, is the most
widely used score to help aid in risk stratification of
patients for testing and treatment for GABHS.
Diagnostic Studies
Diagnostic testing should take a thoughtful, costeffective approach, determining whether or not
a patient has GABHS and avoiding antibiotics in
Table 2. Modified Centor Criteria
Criterion
Score
Fever
1
Physical Examination
Absence of cough
1
The physical examination starts with the vital signs
and continues with a careful inspection inside the
mouth. Trismus (the inability to fully open the jaw)
may indicate the presence of a more severe infection
or abscess. The posterior pharynx should be examined for erythema, swelling, and exudates, as well
as for symmetry. Evidence of cobblestoning may
indicate postnasal drip as an etiology. Peritonsillar
swelling or uvular swelling could alert the emergency clinician to infection of the peritonsillar space
or uvula, respectively. The physical examination
should include palpating the submental space under
Anterior cervical adenitis
1
Tonsillar exudate
1
Age 3-14 years
1
Age 15-44 years
0
Age > 44 years
-1
Score
Risk of Streptococcal Infection48-50
0
1%-2.5%
1
5%-10%
2
11%-17%
3
28%-35%
≥4
51%-53%
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patients with viral infections. This involves using
clinical, epidemiologic, and specific laboratory testing for GABHS. However, testing is controversial
and gold standards are limited by the presence of
colonization. Not surprisingly, different societies
have conflicting recommendations on which patients to test and which test to use. For example, the
ACP guidelines place greater emphasis on decreasing testing, whereas the IDSA guidelines serve to
decrease inappropriate antibiotic use.
Patients with primarily viral symptoms alone
(such as coryza, cough, diarrhea, hoarseness, or
discrete ulcerative stomatitis) do not require further
testing because it is unlikely that a bacterial infection is causing the symptoms.10,47 In patients with
a history of primarily viral symptoms, or 0-1 of the
Centor criteria (see Table 2, page 5), RADTs should
not be done, given these patients are unlikely to
have GABHS.47
For patients without a primary viral syndrome,
clinical features between viral infections and GABHS
have considerable overlap.42 Guideline recommendations diverge when symptoms are not obviously
viral. (See Table 3.) Centor criteria are not very
sensitive, and even subjects with all clinical features
of a scoring system tend to have confirmed GABHS
only around 50% of the time.10,40,49-53
The IDSA guidelines and the AHA/AAP guidelines recommend against empiric treatment based on
Centor criteria alone because of the risk from overuse of antibiotics.10,44 However, the CDC/AAFP/
ACP guidelines consider empiric treatment of
patients with 3 to 4 Centor criteria as an appropriate
option.36 A recent cost-effectiveness analysis found
empiric treatment to be neither the most effective
management strategy nor the least expensive;54 however, some clinicians believe the effect of decreased
pain and suffering that results from antibiotics is
worth the overuse.55 Obviously, this discrepancy deserves our attention and further study, but possibly more concerning
is the number of clinicians who still do not follow
any of these strategies and inappropriately treat
patients with primarily viral symptoms or negative
RADTs.56 While the emergency clinician has a choice
in managing pharyngitis, the best data available
show that one of these strategies should be picked.
Rapid Antigen Detection Testing And Throat
Cultures
Laboratory determination of GABHS is primarily done
with RADTs or a throat culture; throat culture is the
gold standard. A properly performed throat culture
(swabbing the posterior pharynx and tonsils, avoiding
the tongue and lips) is 90% to 95% sensitive.57
The original RADTs used the latex agglutination
technique, but newer RADTs use enzyme immunoassay techniques and optical immunoassay technology, which are more sensitive.58 A recent prospective
study of RADT found, not surprisingly, that sensitivity increased with heavy inoculum, and found
a sensitivity and specificity of 86.7% and 94.6%,
respectively.59 A 2014 systematic review looking at
RADTs in 59 studies and 55,766 patients found the
sensitivity in children to be between 86% and 88%,
and the specificity to be between 86% and 92%. In
adults, sensitivity was 86% to 91%, and specificity
was 93% to 97%.60
Based on data such as these, with proven high
specificity, if a RADT is positive, then treatment is
indicated. Limiting testing on low-risk patients with
2 or more Centor criteria will likely limit false positives from bacterial colonization. If a RADT is negative in a pediatric patient, a throat culture should be
performed.10 However, in adults, it is acceptable to
not send a backup throat culture, based on the lower
incidence of GABHS and the low rates of acute rheumatic fever.10,11,36 This discrepancy can be explained
by the high pretest probability in children (30% in
children vs 5%-15% in adults), as well as the higher
(albeit still very low) probability of acute rheumatic
fever developing in a child versus an adult. Cultures
can be performed on adult patients with risk factors
for complications (eg, immunocompromise, diabetes, history of rheumatic fever). While early initiation of antibiotics can lead to faster resolution of
symptoms of pharyngitis, antibiotic therapy initiated
within 9 days of symptom onset can still prevent
acute rheumatic fever.61
Table 3. Summary Of Guidelines For Pharyngitis
Centor Criteria Score
IDSA Guideline, 2012
(Adults and Children)10
AHA/AAP Guideline,
2009 (Adults and Children)44
CDC/AAFP/ACP Guideline,
2001 (Adults)36
ESCMID Guideline, 2012
(Adults and Children)11
0 or 1
Do not test or treat
Do not test or treat
Do not test or treat
Do not test or treat
2
Perform RADT
Perform RADT
Perform RADT
Do not test or treat
3
Perform RADT
Perform RADT
Perform RADT or treat empirically
Perform RADT
≥4
Perform RADT
Perform RADT
Perform RADT or treat empirically
Perform RADT
Abbreviations: AAFP, American Academy of Family Physicians; AAP, American Academy of Pediatrics; ACP, American College of Physicians; AHA,
American Heart Association; CDC, Centers for Disease Control and Prevention; ESCMID, European Society of Clinical Microbiology and Infectious
Diseases; IDSA, Infectious Diseases Society of America; RADT, rapid antigen detection test.
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colonized, and 40% of contacts colonized develop
symptomatic infection.68
GABHS should be treated with penicillin,
amoxicillin, or benzathine penicillin for 10 days to
ensure eradication of the organism from the pharynx.10,11,36,44 (See Table 4.) Intramuscular repositorypenicillin therapy is the only drug proven to prevent
rheumatic fever,44 and the prolonged course is aimed
at preventing this complication. If the goal is to
treat group C or G streptococcal infection, a shorter
course would be appropriate. In a prospective
randomized controlled trial of 652 patients, amoxicillin administered once daily was proven to be
noninferior to amoxicillin administered twice daily.70
Penicillin and amoxicillin (in addition to being the
only first-line therapy), are also more cost-effective
than other alternatives.44
Diagnostic Studies For Young Children
Diagnostic studies for GABHS are generally not
indicated in children aged < 3 years, given the low
incidence of streptococcal pharyngitis and acute rheumatic fever in this age group.10 Nonsuppurative complications are rare, and the primary benefit to treating
these children is to decrease transmission. The IDSA
and the AAP do not recommend testing these children unless other risk factors are present, such as an
older sibling who is Streptococcus-positive.10,44
Other Laboratory Testing
Most patients with acute pharyngitis do not need
any blood work performed for diagnosis or risk
stratification.11,62 A 2014 Scandinavian study looked
at whether blood tests (procalcitonin, C-reactive
protein [CRP], white blood cell [WBC], and absolute
neutrophil count [ANC]) could increase sensitivity
when used with the Centor score and RADT or if
they could be used instead of RADT.63 The authors
found that, in 100 patients with acute tonsillitis,
the values of CRP, WBC, and ANC were higher
in patients with GABHS, but these tests had low
sensitivity (66%-90%) and low specificity (45%-75%).
There was no difference in procalcitonin levels, and
the additional blood tests did not increase diagnostic
accuracy.63
Additionally, there is no indication for antistreptolysin O (ASO) titers in diagnosing acute pharyngitis, as this laboratory value does not rise until at
least 1 week after the onset of infection.15
Consider other specific testing, if indicated by
the history and physical examination, such as testing
for gonorrhea, chlamydia, human immunodeficiency virus (HIV), or herpes simplex virus, especially in patients with sexual histories indicating the
possibility of these infections. Monospot or EpsteinBarr virus titers should be considered in patients,
especially adolescents, for whom there is concern for
mononucleosis. Other hematologic findings in infectious mononucleosis include a relative lymphocytosis with > 10% atypical lymphocytes.16
Table 4. Antibiotic Treatment Of Group A
Beta Hemolytic Streptococcus Pharyngitis10,44
Dosing
Duration
Penicillin V, oral
• Children (weight < 27 kg):
250 mg bid
• Adults and children ≥ 27 kg:
250 mg qid or 500 mg bid
to tid
10 days
Amoxicillin, oral
• Children: 50 mg/kg qd or 25
mg/kg bid (max 1 gram/day)
• Adults: 500 mg bid
10 days
Penicillin G
benzathine,
intramuscular
• Children (weight < 27 kg):
600,000 units
• Adults and children ≥ 27 g:
1,200,000 units
Once
For patients with penicillin allergy (nonanaphylactic or not
otherwise severe, eg, Stevens-Johnson syndrome, toxic
epidermal necrolysis, etc)
Treatment
Cephalexin, oral
• Children: 40 mg/kg/day divided bid (max 500 mg/dose)
• Adults: 500 mg bid
10 days
Cefadroxil, oral
• Children: 30 mg/kg qd
• Adults: 1 gram qd or 500 mg
bid
10 days
For patients with severe allergy to penicillin
The most salient question regarding patients presenting with pharyngitis is regarding who needs
antibiotics and who does not. Acute streptococcal
pharyngitis is typically a self-limited illness,15 and
inappropriate antibiotic use for upper respiratory
infections has been a major contributor to antibiotic
resistance.63 However, antibiotics are used to decrease symptom duration,9,65,66 to decrease suppurative complications, and to decrease the risk of
acute rheumatic fever.10,67 There is also the hope that
early antibiotic use will decrease infectivity, as the
risk of contagion of symptomatic pharyngitis is approximately 10%, 25% of exposed contacts become
September 2015 • www.ebmedicine.net
Antibiotic
Clindamycin, oral
• 21 mg/kg/day divided tid
(max 300 mg/dose)
10 days
Azithromycin,
oral
• Children aged < 12 y: 12 mg/
kg/day (max 500 mg/day)a
• Adults: 500 mg qdb
5 days
Clarithromycin,
oral
• Children: 15 mg/kg/day divided bid (max 250 mg/dose)
• Adults: 250 mg bid
10 days
a
60 mg/kg total dose has been shown to be more effective.69
Standard adult 5-day pack dosing can be used (500 mg on day 1 and
250 mg on days 2-5).69
Abbreviations: bid, 2 times a day; qd, 1 time a day; qid, 4 times a day;
tid, 3 times a day.
b
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There are several treatment options in patients
with penicillin allergy, and the treatment options
are dependent on the severity of the reaction.
When choosing an alternative antibiotic, one also
must remember that GABHS is generally selflimited disease. In patients with a severe penicillin
allergy (anaphylaxis, Stevens-Johnson syndrome,
or other life-threatening complications), the
emergency clinician could prescribe clindamycin,
clarithromycin, or azithromycin. (See Table 4,
page 7.) However, most patients can tolerate oral
cephalosporins.71 GABHS resistance to penicillin
has never been documented.44 Tetracyclines and
sulfonamides are not recommended due to high
rates of antimicrobial resistance of GABHS and
high treatment failure rates.61
cians published in 1999 reported that the most
common reason given for inappropriate antibiotic
use was “parental pressure.”78 Additionally, for the
time-crunched physician, giving antibiotics without
doing a thorough clinical assessment or waiting for
RADT results can allow for quicker patient visits.
However, this approach leads to overprescribing,
antibiotic side effects, increased medical costs, and
antibiotic resistance.64
While time-consuming, a discussion with the
aim to educate and focus on shared goals, such as
pain relief, can facilitate appropriate decision making. Offering the patient myriad pain control options, including NSAIDs, acetaminophen, lozenges,
hot liquids, gargling salt water, etc, as opposed to
focusing on antibiotics, may decrease inappropriate
antibiotic prescriptions.79
Pain Relief
Fusobacterium And Lemierre Syndrome
For the treatment of pain, the IDSA advises the use
of aspirin or nonsteroidal anti-inflammatory drugs
(NSAIDs) in adults and NSAIDs in children.10
Treatment with steroids is not recommended by the
IDSA or ESCMID guidelines.10,11 Supportive care
includes analgesics (both systemic and topical),
antipyretics, and gargles.47 As with all illnesses,
patients should be told to rest and keep up an
adequate fluid intake.16 The ESCMID guideline also
recommends ibuprofen and acetaminophen for sore
throat pain.11
Most of the data on pain relief are from small
randomized controlled trials, but a systematic
review published in 2000 that reviewed 22 randomized trials of treatments other than antibiotics for
sore throat found that NSAIDs and acetaminophen
are effective in decreasing sore throat pain.72 In a
study of 120 patients, 400 mg of ibuprofen was effective in reducing pain by 80% at 4 hours.73 Other
small randomized controlled trials have shown the
efficacy of benzocaine lozenges (165 patients)74 and
AMC/DCBA (amylmetacresol/2,4-dichlorobenzyl
alcohol) throat lozenges (310 patients).75 There was
no benefit in the addition of a decongestant and antihistamine to acetaminophen, compared to acetaminophen alone, in pain control of viral nasopharyngitis
(148 patients).76 These small studies in support of
over-the-counter treatments give the emergency clinician other modalities for pain control to offer their
patients besides antibiotics.
Lemierre syndrome (postanginal sepsis) is a condition in which a severe sore throat is followed by internal jugular vein thrombosis and septicemia with
multiple septic emboli.18,31 This disease was first described by Andre Lemierre in 1936, but since widespread use of antibiotics began in the 1940s, there
has been a sharp decline in the number of cases.17
There has been an increase in reporting of Lemierre
syndrome over the last decade, but it is difficult
to say whether incidence is increasing or there is
merely an increase in reporting.17 This disease is associated with Fusobacterium necrophorum,18 which is
thought to be a common non-GABHS bacterial cause
of pharyngitis; however, it is often polymicrobial.80
Some authors have postulated that decreased use of
antibiotics in pharyngitis has led to an increase in
cases caused by untreated Fusobacterium infections,81
while others suggest that increased high-resolution
imaging has led to increased diagnosis.17
A 2009 review of the disorder looked at 114
cases reported in the literature and found that the
majority of cases (57%) were thought to be caused
by F necrophorum infections, and an additional 30%
by other Fusobacterium species. This review also
found the majority of infections to have originated
as upper respiratory tract infections, primarily of
the tonsil or pharynx (67%), and the pooled mortality rate was 5%.17
F necrophorum should be treated as a pathogen,
if found. It is normally treated with penicillin and
metronidazole or clindamycin for several weeks.82,83
Anticoagulation for this disorder is controversial,
and given the small number of cases, it is usually
managed by provider preference.17,80 The emergency
clinician should consider this pathogen in the adolescent patient with evidence of significant pharyngitis and concern for bacteremia or sepsis.35
Special Circumstances
Counseling The Patient Who “Wants”
Antibiotics
While over the years, physicians have been successful in decreasing unnecessary prescriptions for
antibiotics,77 there are physicians who feel patients
or parents “want” antibiotics and will not be satisfied without receiving them. A survey of pediatriCopyright © 2015 EB Medicine. All rights reserved.
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Clinical
ForDepartment
Managing Pharyngitis
Clinical Pathway
For Pathway
Emergency
Management Of Multiple
In The Emergency
ShocksDepartment
Airway compromise? (eg, difficulty breathing,
drooling, voice change, stridor, trismus)
YES
Take steps to maintain airway, as needed,
and treat, as appropriate (Class I)
NO
Concern for deep space neck or submandibular abscess?
YES
Initiate further testing, as needed, to determine
etiology and treat, as appropriate
YES
Do not test or treat for GABHS. Treat symptomatically
for likely viral pharyngitis (Class I)
NO
Assess for primary viral syndromes (cough, coryza,
conjunctivitis, headache, muscle aches). Present?
NO
YES
NO
Assess for Centor criteria: (1) fever, (2) absence of cough, (3)
anterior cervical adenitis, and (4) tonsillar exudate.
Only 0-1 present?
YES
Consider other causes for sore throat besides viral illness.
Other etiology more likely?
NO
Only 2 or 3 Centor criteria present?
NO
Treat; do not perform
throat culture (Class I)
• In child, perform throat
culture to confirm
• In adult, do not perform
throat culture; offer
supportive care only
(Class I)
YES
YES/POSITIVE
≥ 4 Centor criteria present?
NO/NEGATIVE
Perform RADT. Positive? (Class I)
YES
Perform RADT; treat if positive.
May consider empiric treatment (Class II)
Abbreviations: GABHS, group A beta hemolytic Streptococcus; RADT, rapid antigen detection test.
Class Of Evidence Definitions
Each action in the clinical pathways section of Emergency Medicine Practice receives a score based on the following definitions.
Class I
Class II
• Always acceptable, safe
• Safe, acceptable
• Definitely useful
• Probably useful
• Proven in both efficacy and effectiveness
Level of Evidence:
Level of Evidence:
• Generally higher levels of evidence
• One or more large prospective studies
• Nonrandomized or retrospective studies:
are present (with rare exceptions)
historic, cohort, or case control studies
• High-quality meta-analyses
• Less robust randomized controlled trials
• Study results consistently positive and
• Results consistently positive
compelling
Class III
• May be acceptable
• Possibly useful
• Considered optional or alternative treatments
Level of Evidence:
• Generally lower or intermediate levels
of evidence
• Case series, animal studies, consensus panels
• Occasionally positive results
Indeterminate
• Continuing area of research
• No recommendations until further
research
Level of Evidence:
• Evidence not available
• Higher studies in progress
• Results inconsistent, contradictory
• Results not compelling
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
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(3.5/1000) and Sub-Saharan Africa (5.7/1000).88 It is
unclear whether this is due to widespread antibiotic
use, different pathogenesis of different strains, or
genetic disposition.89 However, we do know that
antibiotics have been shown to reduce the incidence
of acute rheumatic fever.9,67 Additionally, we know
that in the late 1980s and early 1990s, after acute
rheumatic fever was thought to be almost eradicated
in the United States,90 there were several outbreaks
around the country (Utah, Ohio, Pennsylvania, California, and Tennessee),91 and it is postulated that the
dwindling incidence led to decreased antibiotic use,
which allowed for the resurgence.89
Chronic Group A Beta Hemolytic
Streptococcus Carriers
Chronic GABHS carriers are patients with GABHS
present in the pharynx for an extended period of
time without evidence of infection.84 A 2010 systematic review from Shaikh and colleagues showed
a GABHS carriage rate among children at 12%.4
However, data show that carriers have a low risk for
systemic complications and a low risk for transmission to others.52,84 Additionally, carriers have been
proposed as an explanation for antibiotic treatment
failure,85 as it seems to be more difficult to eradicate
the organism in these patients,86 but this is not typically a problem in the ED. The emergency clinician
should be screening only patients with symptoms
suggestive of GABHS, which should reduce the rate
of false positives.45 Patients with a positive RADT
should be treated with antibiotics.10,44
Other Complications
Antibiotics are also given to decrease the incidence
of suppurative complications. A 2013 Cochrane review showed that antibiotics decrease the incidence
of acute otitis media, sinusitis, and peritonsillar
abscess, but noted that the studies involved were
mostly from before 1975, with only 3 studies done
since 2000.9 The applicability of these results to more
modern populations is in question.
Some researchers have looked into predicting
and preventing suppurative complications in morerecent studies. A 2007 retrospective study showed
that male smokers aged 21 to 40 years are most likely to develop peritonsillar abscess (quinsy).92 This
study by Dunn et al showed that, in a cohort of 606
patients who developed peritonsillar abscess over a
2-year period, only 31% presented with peritonsillar abscess after being treated for an uncomplicated
sore throat. There was no evidence that antibiotics
prevented peritonsillar abscess.92
A 2013 prospective clinical cohort study tried to
identify aspects of the history and physical examination that can predict the likelihood of suppurative
complications. The study investigators followed
14,610 patients with acute sore throat, of which
1.3% developed suppurative complications. Patients
with complications were more likely to have severe
tonsillar inflammation (odds ratio [OR], 1.92) and
severe earache (OR, 3.02), but 70% of complications
occurred when neither was present. The authors
reported both that clinical prediction rules had a
poor predictive value of complications and that antibiotics did not decrease these complications.93 The
authors suggested that clinicians should consider
“delayed antibiotic prescription and safety-net strategies,” given the low prevalence of these complications and the inability to predict them.
Given the low prevalence of suppurative complications, these 2 studies seem to indicate that, in
developed countries, prevention of suppurative
complications is not a valid reason for supplying
antibiotics for group A Streptococcus. However, more
questions should be investigated, such as: Are there
other pathogens or specific group A Streptococcus
Controversies And Cutting Edge
Withholding Antibiotics For Group A Beta
Hemolytic Streptococcus
There is consensus in the American guidelines that
GABHS should be treated with antibiotics,10,44,47
but there are some data that show that antibiotics
for GABHS do not improve outcomes in developed
countries where the prevalence of complications
is low. After all, GABHS is a self-limited disease,15
and antibiotics have side effects, cost money, and
their overuse contributes to resistance. For these
reasons, the ECSMID guidelines do not recommend
treating sore throat with antibiotics to prevent
acute rheumatic fever in low-risk patients.11 However, given the available data, we still feel that appropriate antibiotics are indicated in patients with
GABHS, given the risk of acute rheumatic fever
and other complications.
Acute Rheumatic Fever
Acute rheumatic fever is the most concerning possible complication of GABHS infection. It is an
immune response caused by an antibody-mediated
hypersensitivity reaction that occurs about 2 weeks
after a GABHS infection.87 Components of the cell
wall and membrane of GABHS are similar to common human proteins, leading to immunologic attack
on many systems, including the synovium, brain,
skin, and subcutaneous tissue, and, most importantly, the heart valves. Globally, it is the leading cause
of cardiovascular death in people aged < 50 years.87
It is estimated that there are approximately 15.6 million cases worldwide, with 282,000 new cases and
233,000 deaths each year.88 However, there are very
few cases in developed countries. It is estimated
that the prevalence of acute rheumatic fever in
children aged 5 to 14 years in Europe is only 1/1000
cases, compared to much higher rates in Australia
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strains we should identify that are more likely to
cause these complications? And again, if antibiotic
use declined dramatically, would the rates of these
complications increase?
Indications For Tonsillectomy
Tonsillectomy has declined over the years, but is still
performed in patients with recurrent tonsillitis and
pharyngitis.97 For the emergency clinician, general
knowledge on the indications and benefits of tonsillectomy may be important for counseling the patient
with recurrent pharyngitis. The IDSA does not recommend tonsillectomy "...solely to reduce frequency
of group A streptococcal pharyngitis.”10
A 2014 Cochrane review of surgical versus nonsurgical treatment for tonsillitis analyzed 5 studies
of children (987 patients) and 2 studies of adults (156
patients), and found a modest decline in episodes
of sore throat and total days with sore throat for
children in the first postoperative year. The authors
concluded that the data on outcomes in adults could
not be determined, based on the low quality of
evidence. The authors found no difference in the use
of analgesics and no evidence for decreased use of
antibiotics in posttonsillectomy patients.97
Based on these data, the emergency clinician
could consider consultation with an ear, nose, and
throat specialist regarding tonsillectomy for a patient
with recurrent tonsillitis, especially a child, but the
data do not support this surgery.
Treatment To Reduce Symptom Duration,
Pain, And Contagiousness
There are also data that suggest that treatment reduces symptom duration, pain, and contagiousness.10,65,66
The Cochrane review from 2013 showed the presence
of symptoms (sore throat and fever) were reduced
by about half with antibiotic use, and the duration
of symptoms was shortened by about 16 hours. The
greatest difference was seen at day 3.9 However, there
are not enough data comparing other effective pain
management strategies (NSAIDs, steroids, etc) alone
versus antibiotics alone. Most of these studies focus
on antibiotics in conjunction with pain medications or
pain medications alone versus placebos.
Corticosteroids For Odynophagia
Corticosteroids are regularly used to decrease
inflammation in disorders such as asthma, croup,
mononucleosis, and other upper respiratory infections.94 There is some evidence that the emergency
clinician should be using corticosteroids in sore
throat, but it is controversial, and the IDSA does not
recommend corticosteroids for treatment of GABHS
pharyngitis.10
A 2012 Cochrane review of 8 trials involving
743 patients showed antibiotics with corticosteroids
were 3 times more likely to result in pain resolution
at 24 hours as opposed to antibiotics alone.95 However, there are no trials involving corticosteroids
alone without antibiotics, and this small sample
did not have the power to look for rare complications that could be caused by corticosteroids (such
as immunosuppression, masking other diseases, or
worsening complications).96 This has led some providers to suggest that corticosteroids be used only in
patients with severe symptoms and an inability to
swallow.95 A single dose of oral dexamethasone (0.6
mg/kg, maximum of 10 mg) is recommended.94 In
adults, a single oral daily dose of prednisone 60 mg
for 1 to 2 days is acceptable.95
The literature is also lacking data comparing
corticosteroids to NSAIDs or acetaminophen, which
have been shown to decrease pain in acute pharyngitis.72 These over-the-counter medications may
have fewer complications than corticosteroids and,
given that they are available over the counter, may
decrease costs and physician visits.
Based on the best available evidence, corticosteroids can be considered in patients without risk factors (such as diabetes or immunosuppression) with
severe sore throat, especially those with trismus or
inability to swallow.
September 2015 • www.ebmedicine.net
Disposition
The majority of patients who present with sore
throat will be sent home, so it is important to ensure
that the patient is able to tolerate oral intake and is
not at risk for becoming dehydrated. Of course, if
there is concern for airway compromise, then the
patient should have definitive treatment (eg, intubation, needle aspiration of a peritonsillar abscess,
surgical debridement of a submandibular abscess) or
admission for monitoring.
The patient should be counseled on the possibility of developing suppurative complications with
or without antibiotics. Patients should be advised to
watch for cellulitis, otitis, sinusitis, and deep neck
space abscesses. Patients should also return if symptoms do not resolve within 3 to 5 days, at which
point, other etiologies should be explored. Finally,
patients with a history of acute rheumatic fever or
with an unusually high risk of recurrence (eg, in an
area of acute rheumatic fever outbreak) should have
primary care follow-up for throat culture to ensure
eradication 2 to 7 days after completion of therapy.
Summary
One of the most common chief complaints facing the
emergency clinician is the patient with sore throat
and fever. As always, the first step in the management of these patients is assessing the airway, but in
most patients, there will be no airway compromise.
These infections are primarily caused by viruses,
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Risk Management Pitfalls In Management Of Pharyngitis
1. “It was just a sore throat, so I didn’t think she
needed to be admitted for intravenous fluids.”
Pharyngitis can be a simple diagnosis, but it
is imperative to make sure patients' pain is
adequately controlled so they can maintain an
adequate oral intake. Not assessing a patient's
fluid status and ability to eat and drink
initially and prior to discharge can lead to poor
outcomes and readmissions.
6. “I gave antibiotics, but the patient is very upset
that she developed a peritonsillar abscess and
had to come back.”
While antibiotics have been shown to decrease
suppurative complications, they can still occur.
Patients should be counseled on the possible
complications of pharyngitis and given strict
return precautions and a follow-up plan.
7. “I never felt under his tongue.”
Given the broad differential associated with
pharyngitis, the emergency clinician’s best tool
for success is a thorough history and physical
examination. Ludwig angina or a submandibular
abscess results in a “woody” induration in the
submental space. Forgetting to fully examine the
entire oral cavity or associated structures (skin,
spleen, etc) can result in missed diagnoses.
2. “I discharged him with viral pharyngitis after
a negative RADT. I didn’t expect him to end up
in the intensive care unit with multiple septic
emboli.”
Lemierre syndrome is a rare but well-described
complication of pharyngitis, normally
associated with Fusobacterium spp, not GABHS.
It is most commonly seen in adolescent
patients shortly outside of the “acute” (3-5
day) pharyngitis window, with internal jugular
venous thrombosis and sepsis. Patients should
always be given clear return precautions and
follow-up plans.
8. “The patient reported a penicillin allergy, so I
gave cephalexin. I never asked what the reaction was.”
Penicillin is the treatment of choice for GABHS
pharyngitis, but in penicillin-allergic patients,
there are other options. Cephalosporins have
low cross-reactivity to penicillin, have been
proven effective against GABHS, and can be
used if a patient had a minor reaction. However,
if a patient had a severe allergy to penicillin
such as anaphylaxis, Stevens-Johnson syndrome,
or other airway involvement, cephalosporins
should not be used.
3. “I didn’t ask about his sexual history.”
Gonorrhea can cause an exudative pharyngitis,
and should be considered in the broad
differential for pharyngitis. Chlamydia
trachomatis, HIV, and herpes simplex virus can
all also produce pharyngeal syndromes and
symptoms. Failing to take a good history can
prevent diagnosis of these conditions.
4. “She told me her voice sounded funny, but it
sounded fine to me.”
Patients presenting with sore throat can have
serious airway complications. Voice change
should be considered to be a sign of deep space
neck infection or epiglottitis and should be
further investigated with direct visualization or
imaging to identify a cause.
9. “I saw the patient yesterday and diagnosed
her with viral pharyngitis. She didn’t need any
treatment. I don’t know why she is back.”
Pharyngitis can be very painful for patients,
and even if antibiotics are not prescribed,
the emergency clinician should counsel the
patient on methods for pain control. NSAIDs,
acetaminophen, lozenges, and gargles can all be
effective. Even though most of these medications
are available over the counter, patients should
still be instructed on what to use and how to use
them in order to prevent repeat visits.
5. “He had a cough, runny nose, and hoarseness,
but I still gave penicillin for his sore throat. He
had never had an allergic reaction to an antibiotic before.”
Inappropriate use of antibiotics can lead to
unnecessary costs, antibiotic resistance, and
allergic or other unpleasant reactions for patient.
Antibiotic use should be limited to only those
patients with a clear indication. Patients with
obvious evidence of viral pharyngitis, or only
0-1 score on Centor criteria should not be treated
with antibiotics.
Copyright © 2015 EB Medicine. All rights reserved.
10. “It was just a sore throat. Why would I think
about cancer?”
Infectious pharyngitis should last only 3 to 5
days, and anyone presenting with a longer course
needs a broader differential. In older patients or
patients with other risk factors for malignancy
(smoking, obesity, heavy alcohol use), it must be
considered, or it will most certainly be missed.
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and GABHS infections are usually self limiting, but
current guidelines still recommend treatment of
GABHS to rule out suppurative and systemic complications. The emergency clinician should also not
forget the broad differential for this complaint, and
should screen for other etiologies, such as mononucleosis or gonococcal pharyngitis. This requires
a thorough history and physical examination, but
a history and physical examination alone are not
enough to distinguish viral from bacterial pharyngitis. The emergency clinician should use the Centor
criteria and obvious evidence of a viral infection to
guide the use of RADTs, with confirmatory throat
cultures in children, but not in adults. Treatment
of GABHS should be with penicillin or amoxicillin
unless the patient has an allergy to these antibiotics.
Pain should be managed with NSAIDs, acetaminophen, and throat lozenges, and patients should be
counseled on return precautions, given the chance of
persistent infection or complications.
nopathy, and no cough). Based on the ambiguity in the
guidelines and the preference at your facility, you knew
you could empirically treat him or send a RADT. You also
remembered to take a good sexual history from this patient
and considered sending a throat swab for gonorrhea and
chlamydia. You decided to send the RADT, and, given
the positive result, you prescribed penicillin for a 10-day
course. You discharged him with a plan for pain control
and monitoring for complications.
You were concerned about the 35-year-old woman
with 5 days of sore throat and voice changes. You remembered that most acute pharyngitis resolves in 3 to 5 days
and should not involve voice changes, so you decided to
consult the ENT specialist to help with a fiber-optic nasopharyngoscopy. Because of concern for epiglottic swelling,
the patient was admitted for airway monitoring, intravenous antibiotics, and intravenous steroids.
Your 65-year-old male patient was also concerning,
and you realized you could not rule out malignancy in
this older male smoker. Given the duration of symptoms
and lack of other infectious symptoms, this patient also
did not likely have infectious pharyngitis. You scheduled
an urgent ENT appointment for him within the next few
days, and discharged him with pain control after expressing your concerns and the need for close follow-up.
Case Conclusions
For your two-and-a-half-year-old patient with sore throat
and fever, you remembered that children younger than 3
years of age with group B streptococcal infection may present with atypical symptoms, but they are unlikely to have
GABHS and do not require testing or treatment unless there
is a close contact with the disease. You counseled the patient’s
mother on appropriate use of NSAIDs and acetaminophen
and on monitoring for complications, and then discharged
the toddler.
The 20-year-old patient met all 4 Centor criteria
(fever, tonsillar exudates, tender cervical lymphade-
References
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are
equally robust. The findings of a large, prospective,
random­ized, and blinded trial should carry more
weight than a case report.
To help the reader judge the strength of each
reference, pertinent information about the study will
be included in bold type following the ref­erence,
where available. In addition, the most informative
references cited in this paper, as determined by the
authors, will be noted by an asterisk (*) next to the
number of the reference.
Time- And Cost-Effective
Strategies
• Do not test or treat with antibiotics if the
patient has primarily viral symptoms (eg,
cough, coryza, conjunctivitis, diarrhea). These
symptoms indicate it is unlikely the patient has
GABHS.
• Use penicillin or amoxicillin unless the patient
is allergic to them. Other options are more expensive and have not proven to be more effective against GABHS.
• Do not order a RADT if you plan to treat the
patient anyway. Either treat empirically or treat
based on the RADT. Otherwise, you are wasting
money on testing that you are not using in your
clinical decision.
• Do not order a throat culture in adults with
negative RADTs. The sensitivity of these tests
is high, the incidence of GABHS is low, and
the incidence of serious complications in adult
patients is even lower.
September 2015 • www.ebmedicine.net
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44. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of
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streptococcal pharyngitis: a scientific statement from the
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and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council
on Functional Genomics and Translational Biology, and the
Interdisciplinary Council on Quality of Care and Outcomes
Research: endorsed by the American Academy of Pediatrics.
Circulation. 2009;119(11):1541-1551. (Guideline)
45. Jaggi P, Shulman ST. Group A streptococcal infections. Pediatr Rev. 2006;27(3):99-105. (Review)
46. Mackenzie A, Fuite LA, Chan FT, et al. Incidence and patho-
14
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Snow V, Mottur-Pilson C, Cooper RJ, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann
Intern Med. 2001;134(6):506-508. (Guideline)
McIsaac WJ, White D, Tannenbaum D, et al. A clinical score
to reduce unnecessary antibiotic use in patients with sore
throat. CMAJ. 1998;158(1):75-83. (Prospective study; 521
patients)
McIsaac WJ, Goel V, To T, et al. The validity of a sore throat
score in family practice. CMAJ. 2000;163(7):811-815. (Prospective; 619 patients)
McIsaac WJ, Kellner JD, Aufricht P, et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA. 2004;291(13):1587-1595. (Prospective
observational study; 787 patients)
Breese BB. A simple scorecard for the tentative diagnosis of
streptococcal pharyngitis. Am J Dis Child.1977;131(5):514-517.
(Prospective observational study; 670 patients)
Kaplan EL. Streptococcal pharyngitis in adults: can it be
efficiently and effectively managed by remote control? Ann
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Fine AM, Nizet V, Mandl KD. Large-scale validation of the
Centor and McIsaac scores to predict group A streptococcal
pharyngitis. Arch Intern Med. 2012;172(11):847-852. (Retrospective observational; 206,870 patients)
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management of adults with pharyngitis. A cost-effectiveness
analysis. Ann Intern Med. 2003;139(2):113-122. (Cost-effectiveness analysis)
Centor RM, Allison JJ, Cohen SJ. Pharyngitis management:
defining the controversy. J Gen Intern Med. 2007;22(1):127130. (Review)
Park SY, Gerber MA, Tanz RR, et al. Clinicians’ management
of children and adolescents with acute pharyngitis. Pediatrics. 2006;117(6):1871-1878. (Prospective study; 948 subjects)
Gerber M. Diagnosis of pharyngitis: methodology of throat
cultures. In: Shulman ST, ed. Pharyngitis: Management In
An Era Of Declining Rheumatic Fever. New York: Praeger;
1984:61-72. (Textbook)
Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev.
2004;17(3):571-580. (Review)
Cohen JF, Chalumeau M, Levy C, et al. Effect of clinical
spectrum, inoculum size and physician characteristics on
sensitivity of a rapid antigen detection test for group A
streptococcal pharyngitis. Eur J Clin Microbiol Infect Dis.
2013;32(6):787-793. (Prospective study; 1776 samples)
Stewart EH, Davis B, Clemans-Taylor BL, et al. Rapid
antigen group A Streptococcus test to diagnose pharyngitis: a systematic review and meta-analysis. PloS One.
2014;9(11):e111727. (Systematic review; 55,766 patients)
Bisno AL, Gerber MA, Infectious Diseases Society of
America, et al. Practice guidelines for the diagnosis and
management of group A streptococcal pharyngitis. Infectious
Diseases Society of America. Clin Infect Dis. 2002;35(2):113125. (Guideline)
Bird JH, Biggs TC, King EV. Controversies in the management of acute tonsillitis: an evidence-based review. Clin
Otolaryngol. 2014;39(6):368-374. (Review)
Christensen AM, Thomsen MK, Ovesen T, et al. Are procalcitonin or other infection markers useful in the detection
of group A streptococcal acute tonsillitis? Scand J Infect Dis.
2014;46(5):376-383. (Prospective study; 100 patients)
McCaig LF, Besser RE, Hughes JM. Trends in antimicrobial prescribing rates for children and adolescents. JAMA.
2002;287(23):3096-3102. (Retrospective observational)
Randolph MF, Gerber MA, DeMeo KK, et al. Effect of antibiotic therapy on the clinical course of streptococcal pharyn-
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gitis. J Pediatr. 1985;106:870-875. (Prospective observational;
260 patients)
Krober MS, Bass JW, Michels GN. Streptococcal pharyngitis. Placebo-controlled double-blind evaluation of clinical
response to penicillin therapy. JAMA. 1985;253(9):1271-1274.
(Randomized controlled trial; 44 patients)
Robertson KA, Volmink JA, Mayosi BM. Antibiotics for the
primary prevention of acute rheumatic fever: a meta-analysis. BMC. 2005;5(1):11. (Systematic review)
Musher DM. How contagious are common respiratory tract
infections? N Engl J Med. 2003;348(13):1256-1266. (Review)
Casey JR, Pichichero ME. Higher dosages of azithromycin
are more effective in treatment of group A streptococcal
tonsillopharyngitis. Clinical Infect Dis. 2005;40(12):17481755. (Meta-analysis; 19 randomized controlled trials, 4626
patients)
Clegg HW, Ryan AG, Dallas SD, et al. Treatment of streptococcal pharyngitis with once-daily compared with twicedaily amoxicillin: a noninferiority trial. Pediatr Infect Dis
J. 2006;25(9):761-767. (Randomized controlled trial; 541
patients)
Pichichero ME. A review of evidence supporting the American Academy of Pediatrics recommendation for prescribing
cephalosporin antibiotics for penicillin-allergic patients.
Pediatrics. 2005;115(4):1048-1057. (Review)
Thomas M, Del Mar C, Glasziou P. How effective are treatments other than antibiotics for acute sore throat? Br J Gen
Pract. 2000;50(459):817-820. (Systematic review)
Schachtel BP, Fillingim JM, Thoden WR, et al. Sore throat
pain in the evaluation of mild analgesics. Clin Pharmacol
Ther. 1988;44(6):704-711. (Randomized controlled trial; 120
patients)
Chrubasik S, Beime B, Magora F. Efficacy of a benzocaine
lozenge in the treatment of uncomplicated sore throat. Eur
Arch Otorhinolaryngol. 2012;269(2):571-577. (Randomized
controlled trial; 165 patients)
McNally D, Simpson M, Morris C, et al. Rapid relief of acute
sore throat with AMC/DCBA throat lozenges: randomised
controlled trial. Int J Clin Pract. 2010;64(2):194-207. (Randomized controlled trial; 310 patients)
Unuvar E, Yildiz I, Kilic A, et al. Is acetaminophen as effective as an antihistamine-decongestant-acetaminophen
combination in relieving symptoms of acute nasopharyngitis
in children? A randomised, controlled trial. Int J Pediatr Otorhinolaryngol. 2007;71(8):1277-1285. (Randomized controlled
trial; 148 patients)
Kumar S, Little P, Britten N. Why do general practitioners
prescribe antibiotics for sore throat? Grounded theory interview study. BMJ. 2003;326(7381):138. (Prospective study; 40
participants)
Bauchner H, Pelton SI, Klein JO. Parents, physicians, and
antibiotic use. Pediatrics. 1999;103(2):395-401. (Prospective
survey)
Mangione-Smith R, Elliott MN, Stivers T, et al. Ruling out
the need for antibiotics: are we sending the right message?
Arch Pediatr Adolesc Med. 2006;160(9):945-952. (Cross sectional study; 38 pediatricians, 522 parents)
Agrafiotis M, Moulara E, Chloros D, et al. A case of Lemierre
syndrome and the role of modern antibiotics and therapeutic anticoagulation in its treatment. Am J Emerg Med.
2015;33(5):733:e3-e4. (Case report)
Ramirez S, Hild TG, Rudolph CN, et al. Increased diagnosis
of Lemierre syndrome and other Fusobacterium necrophorum
infections at a children’s hospital. Pediatrics. 2003;112(5):e380.
(Retrospective study; 16 patients)
Jensen A, Hagelskjaer Kristensen L, et al. Minimum requirements for a rapid and reliable routine identification and antibiogram of Fusobacterium necrophorum. Eur J Clin Microbiol
Infect Dis. 2008;27(7):557-563. (Retrospective; 357 isolates)
Mitchell MS, Sorrentino A, Centor RM. Adolescent pharyngi-
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CME Questions
tis: a review of bacterial causes. Clin Pediatr. 2011;50(12):10911095. (Review)
Tanz RR, Shulman ST. Chronic pharyngeal carriage of group
A streptococci. Pediatr Infect Dis J. 2007;26(2):175-176. (Review)
Pichichero ME, Casey JR. Systematic review of factors
contributing to penicillin treatment failure in Streptococcus
pyogenes pharyngitis. Otolaryngology. 2007;137(6):851-857.
(Systematic review)
Gastanaduy AS, Kaplan EL, Huwe BB, et al. Failure of penicillin to eradicate group A streptococci during an outbreak
of pharyngitis. Lancet. 1980;2(8193):498-502. (Retrospective
cohort study; 169 patients)
Martin WJ, Steer AC, Smeesters PR, et al. Post-infectious
group A streptococcal autoimmune syndromes and the
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Carapetis JR, Steer AC, Mulholland EK, et al. The global
burden of group A streptococcal diseases. Lancet Infect Dis.
2005;5(11):685-694. (Review)
Essop MR, Peters F. Contemporary issues in rheumatic
fever and chronic rheumatic heart disease. Circulation.
2014;130(24):2181-2188. (Review)
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the United States: lessons in the rise and fall of disease. T.
Duckett Jones Memorial Lecture. Circulation. 1985;72(6):11551162. (Review)
Congeni BL. The resurgence of acute rheumatic fever in the
United States. Pediatr Ann. 1992;21(12):816-820. (Review)
Dunn N, Lane D, Everitt H, et al. Use of antibiotics
for sore throat and incidence of quinsy. Br J Gen Pract.
2007;57(534):45-49. (Retrospective data analysis; 606 patients)
Little P, Stuart B, Hobbs FD, et al. Predictors of suppurative
complications for acute sore throat in primary care: prospective clinical cohort study. BMJ. 2013;347:f6867. (Prospective
clinical cohort study; 14,610 patients)
Schams SC, Goldman RD. Steroids as adjuvant treatment of
sore throat in acute bacterial pharyngitis. Can Fam Physician.
2012;58(1):52-54. (Review)
Hayward G, Thompson MJ, Perera R, et al. Corticosteroids
as standalone or add-on treatment for sore throat. Cochrane
Database Syst Rev. 2012;10:CD008268. (Systematic review;
743 patients)
Hauswald M. Steroids and throat pain. Ann Emerg Med.
2014;64(6):685-686. (Comment)
Burton MJ, Glasziou PP, Chong LY, Venekamp RP. Tonsillectomy or adenotonsillectomy versus non-surgical treatment
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Rev. 2014;11:CD001802. (Systematic review; 987 children,
156 adult patients)
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www.ebmedicine.net/E0915.
1. Which of the following statements regarding
the epidemiology of pharyngitis is TRUE?
a. Most cases of pharyngitis are due to GABHS.
b. GABHS is more common in adults than children.
c. GABHS is more common in the late winter and early spring in temperate climates.
d. GABHS is transmitted via direct contact.
2. An 18-month-old patient presents with poor
oral intake and difficulty swallowing. Her
mother is concerned for strep throat and would
like antibiotics. You do a full history and physical examination and find a vaccinated only child
with moist mucous membranes and mild pharyngeal edema, but no exudates. You should:
a. Prescribe a 10-day course of penicillin for presumed strep throat
b. Send a RADT and treat if positive
c. Send a throat culture and treat if positive
d. Counsel the mother on how her daughter does not likely have strep and does not need antibiotics for sore throat
3. A 25-year-old man presents with 2 days of sore
throat and fever. He has tender cervical lymphadenopathy and no cough. He is able to drink
liquids without difficulty and is otherwise well
appearing. An appropriate test to order on this
patient is:
a. Complete metabolic panel
b.RADT
c. C-reactive protein
d. Absolute neutrophil count
Copyright © 2015 EB Medicine. All rights reserved.
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4. A 25-year-old man presents with sore throat
and fever. He has no cough or rhinorrhea. On
examination, he has tender cervical nodes and
pharyngeal exudate without distortion of the
pharyngeal anatomy. The RADT is positive. He
is allergic to penicillin. Appropriate treatment
options include all of the following EXCEPT:
a. Treat with amoxicillin
b. Treat with clindamycin
c. Find out the patient's reaction to penicillin, and, if mild, prescribe a first-generation cephalosporin
d. Treat with erythromycin
8. Sore throat associated with septic emboli, especially including the internal jugular vein, is
known as:
a. Lemierre syndrome
b. Vincent angina
c. Ludwig angina
d. Oropharyngeal tularemia
9. Corticosteroids for treatment of pain associated
with acute pharyngitis:
a. Should be considered in all patients who present to the ED
b. Have been proven to decrease symptom duration
c. Should be given for a short course of 5 to 7 days
d. Have been proven safe without concomitant antibiotics
5. An emergency clinician should not perform a
RADT on patients with primarily viral symptoms and/or only 1 Centor criterion for all of
the following reasons EXCEPT:
a. To decrease costs
b. To decrease ED length of stay
c. Chronic carriage of GABHS is common and may result in a false-positive result
d. They should have a throat culture instead
10. Which of the following statements regarding
tonsillectomy is TRUE?
a. Tonsillectomy is routinely indicated for patients with recurrent sore throat.
b. Tonsillectomy should only be considered in patients with > 10 episodes of sore throat a year.
c. Tonsillectomy is not recommended solely to reduce episodes of GABHS pharyngitis.
d. After tonsillectomy, most patients are unlikely to have recurrent episodes of pharyngitis.
6. A 25-year-old man presents with sore throat
and fever. He has no cough or rhinorrhea. On
examination, he has tender cervical nodes and
pharyngeal exudate without distortion of the
pharyngeal anatomy. The RADT is positive. He
has no allergies to medications. First-line treatment is:
a.Penicillin
b. Azithromycin
c.Cephalexin
d. Clindamycin
7. A 25-year-old man presents with sore throat
and fever. He has a runny nose and a cough.
On examination, he has bilateral pharyngeal
erythema without exudates and no distortion
of the pharyngeal anatomy. You should:
a. Perform a RADT and, if negative, send a throat culture.
b. Perform a RADT, but do not send a throat culture if negative.
c. Perform no testing and treat symptomatically for viral pharyngitis.
d. Treat GABHS presumptively with penicillin.
September 2015 • www.ebmedicine.net
17
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Physician CME Information
Date of Original Release: September 1, 2015. Date of most recent review: August 10,
2015. Termination date: September 1, 2018.
SPECIAL
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Medicine Practice Mobile
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Mobile-optimized content from Emergency
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will enable you to instantaneously search
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access to hundreds of topics on your mobile
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Content will be updated in real time so
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soon as they are released. The new app also
features easy-to-use reference tools, such as
bookmarking and note-taking, that enable
you to easily follow up on cases and finish
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We are excited to bring you this new
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Medical Education (ACCME) to provide continuing medical education for physicians. This
activity has been planned and implemented in accordance with the Essential Areas and
Policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4
AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate
with the extent of their participation in the activity.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of
Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: This Medical Journal activity, Emergency Medicine Practice, has
been reviewed and is acceptable for up to 48 Prescribed credits by the American
Academy of Family Physicians per year. AAFP accreditation begins July 1, 2015. Term
of approval is for one year from this date. Each issue is approved for 4 Prescribed
credits. Credit may be claimed for one year from the date of each issue. Physicians
should claim only the credit commensurate with the extent of their participation in the
activity.
AOA Accreditation: Emergency Medicine Practice is eligible for up to 48 American
Osteopathic Association Category 2-A or 2-B credit hours per year.
Needs Assessment: The need for this educational activity was determined by a survey
of medical staff, including the editorial board of this publication; review of morbidity
and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior
activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine
physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate
medical decision-making based on the strongest clinical evidence; (2) cost-effectively
diagnose and treat the most critical presentations; and (3) describe the most common
medicolegal pitfalls for each topic covered.
Discussion of Investigational Information: As part of the journal, faculty may be
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promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance,
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In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for
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received is as follows: Dr. Hildreth, Dr. Takhar, Dr. Clark, Dr. Hatten, Dr. Damilini,
Dr. Toscano, Dr. Jagoda and their related parties report no significant financial
interest or other relationship with the manufacturer(s) of any commercial
product(s) discussed in this educational presentation.
Commercial Support: This issue of Emergency Medicine Practice did not receive any
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Emergency Medicine Practice (ISSN Print: 1524-1971, ISSN Online: 1559-3908, ACID-FREE) is published monthly (12 times per year) by EB Medicine (5550 Triangle Parkway, Suite
150, Norcross, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is
intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used
for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Copyright © 2015 EB Medicine. All rights
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Copyright © 2015 EB Medicine. All rights reserved.
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