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FAMILY PRACTICE BOARD REVIEW MANUAL
PUBLISHING STAFF
PRESIDENT, GROUP PUBLISHER
Bruce M. White
EXECUTIVE EDITOR
Debra Dreger
SENIOR EDITOR
Becky Krumm, ELS
EDITOR
Upper Respiratory
Infections II: Pharyngitis
Series Editor and Contributing Author:
Miriam T. Vincent, MD
Associate Professor, Interim Chair, Department of Family Practice, State
University of New York, Health Science Center at Brooklyn, Brooklyn, NY
Ellen M. McDonald, PhD
ASSISTANT EDITOR
Jennifer M. Vander Bush
EDITORIAL ASSISTANT
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Contributing Authors:
Nadhia Celestin, MD
Faculty Development Fellow, Clinical Assistant Instructor, Department of
Family Practice, State University of New York, Health Science Center at
Brooklyn, Brooklyn, NY
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Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Case Presentations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
NOTE FROM THE PUBLISHER:
This publication has been developed
without involvement of or review by the
American Board of Family Practice.
Endorsed by the
Association for Hospital
Medical Education
The Association for Hospital Medical Education
endorses HOSPITAL PHYSICIAN for the purpose of presenting the latest developments in
medical education as they affect residency programs and clinical hospital practice.
Types of Pharyngitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Management of Pharyngitis. . . . . . . . . . . . . . . . . . . . . . . . . 7
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Board Review Questions . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Suggested Readings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
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Family Practice Volume 4, Part 4 1
FAMILY PRACTICE BOARD REVIEW MANUAL
Upper Respiratory Infections II: Pharyngitis
Series Editor and Contributing Author:
Miriam T. Vincent, MD
Associate Professor
Interim Chair
Department of Family Practice
State University of New York
Health Science Center at Brooklyn
Brooklyn, NY
Contributing Authors:
Nadhia Celestin, MD
Bridget Earle, MSIII
Faculty Development Fellow
Clinical Assistant Instructor
Department of Family Practice
State University of New York
Health Science Center at Brooklyn
Brooklyn, NY
Senior Medical Student
College of Medicine
State University of New York
Health Science Center at Brooklyn
Brooklyn, NY
INTRODUCTION
Pharyngitis is defined as an inflammation of the
pharynx, the musculomembranous passage located
between the mouth, the posterior nares, and the larynx.
Sore throat is the most common presenting symptom in
patients with pharyngitis, just as it is one of the most
common presenting symptoms of patients throughout
the primary care setting in the United States.1,2
In the past, in patients infected with group A
β- hemolytic streptococci (GABHS), pharyngitis was
often associated with the life-threatening complication of acute rheumatic fever (ARF). As a result, primary care providers generally have aggressively treated sore throats, with this complication in mind. In
reality, the actual incidence of ARF has dramatically
decreased and is now only approximately 64 per
100,000 cases.3 According to published accounts,
antibiotics are prescribed to 34% to 75% of patients
2 Hospital Physician Board Review Manual
diagnosed with pharyngitis.4 However, of the 30 million cases of pharyngitis diagnosed annually, only
approximately 20% have a clear indication (ie, infection with GABHS) for use of antibiotics.1
Pharyngitis can be categorized broadly as having
either a viral or a bacterial etiology. Although other
causes exist (eg, allergies, overuse of the voice, foreign
body irritation, clinical entities such as Kawasaki syndrome), most cases fall into 1 of these 2 categories.
Pharyngitis of viral etiology, the most common cause of
sore throat, is generally benign and self-limited in
nature5; viral sore throats for the most part are associated with systemic symptoms of fatigue, headache,
malaise, and mild elevation of temperature. More serious sequelae and a greater morbidity are associated
with bacterial pharyngitis.
In order to manage pharyngitis appropriately in
patients with sore throat, primary care physicians must
be able to distinguish between its different causes and
know when it is justifiable to treat the illness (eg, with
Pharyngitis
antibiotics). Such knowledge can help prevent patients
from consuming needless remedies and antibiotics that
are both costly and often ineffective. Family practitioners
need to educate their patients on the natural course of
the illness while resisting patients’ insistence on unnecessary antibiotics. To help in this regard, the following
review will discuss the various types of pharyngitis, providing information on their etiology, epidemiology, diagnosis, and management. This article is the second installment of a 2-part series on upper respiratory infections.
The first installment, published in Volume 4 Part 1 of the
Family Practice Board Review Manual, addressed the evaluation and management of otitis media, acute bronchitis,
and sinusitis.
Table 1. Common Causes of Viral Pharyngitis
Rhinoviruses (20%)*
Adenoviruses (5%)*
Coronavirus (5%)*
Epstein-Barr virus (5%)*
Herpes simplex virus (5%)*
Influenza virus (5%)*
Cytomegalovirus (1%)*
Enteroviruses such as poliovirus, coxsackievirus, echovirus
(1%)*
Respiratory syncytial virus (1%)*
*The percentage listed represents the percentage of all pharyngitides.
CASE PRESENTATIONS
CASE 1
A 14-year-old boy sees his family practitioner because
of a 1-week history of sore throat. He is afebrile and has
mild nasal congestion and cough, rhinorrhea, and signs
of conjunctivitis. Medical history is not significant, and
he is currently up-to-date in his childhood immunizations. His mother says that he has not been sick during
the past 2 years. She further reports recently discovering
condoms in his room. Physical examination reveals a
tall, mildly obese adolescent in no apparent distress.
Examination of the pharynx shows enlarged, erythematous tonsils with patches of yellow purulent exudate.
Cervical adenopathy is present, as are boggy nasal turbinates and mild conjunctival injections. There are no
other pertinent findings.
• What is the most likely diagnosis?
• What methods should be used to confirm the diagnosis?
• When should antibiotics be prescribed, if at all?
• What is the most appropriate treatment of Patient 1?
CASE 2
A previously healthy 6-year-old boy is brought to a
family practice center because of a 1-day history of abdominal discomfort, nausea, and an episode of vomiting. His immunization status is up-to-date. His mother
is concerned that he might have appendicitis. On further questioning, the boy reports that his throat has
been sore since early morning and that there is discomfort when he swallows.
Oral temperature is 101.7°F (38.7°C). Physical examination reveals a strawberry tongue, palatal petechiae,
hypertrophied erythematous tonsils with a patchy white
exudate, bilaterally enlarged and tender superior cervical lymph nodes, and mild abdominal tenderness without rebound. There is no conjunctivitis, congestion,
rash, or other significant finding.
• What is the most likely diagnosis?
• What test(s) should be ordered at this point?
• Should antibiotics be administered before test results are known?
• What is the most appropriate treatment of Patient 2?
TYPES OF PHARYNGITIS
VIRAL PHARYNGITIS
Etiology and Epidemiology
Viral pharyngitis occurs in all age groups.1,6 Its course
is mostly self-limited, generally lasting 3 to 7 days with an
outside limit of 7 to 10 days. As a group, viruses represent
the most common cause of pharyngitis.7 Approximately
40% to 50% of all cases of acute pharyngitis are of viral
etiology.7 Rhinovirus and adenovirus are most often the
causative agents leading to viral pharyngitis, although
Epstein-Barr virus, herpes simplex virus (HSV), influenza virus, and enteroviruses (eg, poliovirus, coxsackievirus,
echovirus) can also be responsible (Table 1).5,8
Some viruses are more prevalent in certain seasons.
For example, rhinovirus outbreaks commonly occur
during the early fall and late spring, whereas respiratory syncytial virus outbreaks peak in January. Adenovirus
and coronavirus epidemics tend to occur in winter and
spring, especially in institutions (eg, nursing homes)
and among military recruits.9 Sore throats that occur in
Family Practice Volume 4, Part 4 3
Pharyngitis
Table 2. Common Symptoms and Signs of Viral
Pharyngitis
Table 4. Other Causes of Pharyngitis
Allergy
Classically suggestive symptoms
Foreign body*
Conjunctivitis
Coryza
Fungal infection (eg, candidiasis/thrush; more severe in
immunosuppressed patients)
Cough
Gastroesophageal reflux disease
Hoarseness
Kawasaki syndrome*
Low-grade fever*
Lymphoma/leukemia/subacute thyroiditis causing referred pain
Malaise/fatigue with headache
Oropharyngeal carcinoma
Mouth-breathing*
Overuse of the voice
Rapid onset of symptoms
Peritonsillar abscess (quinsy)
Sore/scratchy throat
Retropharyngeal abscess
Classically suggestive physical signs
Trauma
Erythema
*Especially in pediatric populations.
Pale, swollen, or boggy pharynx
Scanty exudate/no exudates
Vesicles/oral ulcers
*In pediatric populations.
Table 3. Organisms That Commonly Cause Bacterial
Pharyngitis
Streptococcus pyogenes* (20%)†
Mycoplasma pneumoniae (5%)†
Arcanobacterium haemolyticum (< 5%)†
Neisseria gonorrhoeae (< 1%)†
Corynebacterium diphtheriae (< 1%)†
*Group A β-hemolytic streptococcus.
†The percentage listed represents the percentage of all pharyngitides.
the summer or year-round in temperate climates are
largely caused by enteroviruses.10
Diagnosis
Obtaining a complete history and performing a
thorough physical examination are both essential to
making the diagnosis of viral pharyngitis. The patient
should be asked about possible exposure to infection,
past illnesses, and travel. During elicitation of the history, it is essential to derive information about the onset,
progression, and severity of the sore throat and any associated symptoms (eg, fatigue, headache, malaise, and
elevation of temperature). Findings that are classically
suggestive of viral pharyngitis include cough, fever, ear-
4 Hospital Physician Board Review Manual
ache, congestion, lymphadenopathy, vesicles, and oral
ulcers (Table 2). Although viral pharyngitis usually is
self-limited and benign in nature, generally has symptoms of rapid onset and resolution, and involves sore
throat in 65% to 95% of cases,1 some patients have a
more severe presentation. Signs of conjunctivitis, rhinitis, mild erythema of the pharynx, and edema can be
discovered in patients with the illness.
In establishing a differential diagnosis for patients with
sore throats, clinicians should consider all possible causes of pharyngitis (Table 1; Tables 3 and 4). In adolescents
who have had a prolonged course of pharyngitis, the primary care provider should first consider infectious
mononucleosis as a possible diagnosis, with Epstein-Barr
virus as the etiologic agent. Infectious mononucleosis is a
clinical syndrome most commonly seen in adolescents
and young adults.11 Although the clinical picture can vary
in severity, the triad of lymphadenopathy, splenomegaly,
and exudative pharyngitis usually is found in patients
with infectious mononucleosis. The hallmark of infectious mononucleosis is the appearance of the classic prodromal symptoms of fever, chills, fatigue, malaise, severe
sore throat, tonsillopharyngitis, and posterior cervical
lymphadenopathy. A subset of individuals with these prodromal symptoms will progress to develop hepatosplenomegaly (30% to 50%),11 periorbital edema (20%),11
palatal petechiae,1,5 and characteristic rash (approximately 5%).11,12
To confirm the diagnosis of infectious mononucleosis,
clinicians should consider using the heterophil antibody
(Monospot) test as a helpful adjunct in a suggestive clinical setting.4 The diagnosis of infectious mononucleosis is
usually made on the basis of the clinical presentation and
Pharyngitis
positive results of a heterophil antibody test.11 Ancillary
laboratory findings and results of specific serologic tests
for Epstein-Barr virus also can support the clinical diagnosis of infectious mononucleosis.
HSV is one of the common causes of acute pharyngitis associated with vesicles and ulcers.13 HSV pharyngitis is a disease primarily of neonates, children, and
adolescents.13 The special trait of the herpesvirus is its
latency after primary infection.13 The differential diagnosis of HSV includes herpangina caused by coxsackievirus A, acute membranous tonsillitis, hand-footand-mouth disease, and thrush. The location of the
oral ulcer suggests a specific diagnosis. An anteriorly
located ulcer is generally indicative of herpetic lesions.
Posteriorly located ulcers (eg, apthous ulcers, oral ulcers in patients with herpangina) suggest infection
with an enterovirus.13 The triad of fever, constitutional
symptoms, and orogenital vesicular exanthems/enanthemas, when present, suggests the diagnosis of HSV.
Confirmation of HSV is possible through various
means, including fluorescent antibody detection and
discovery of viral isolates in a vesicle/lesion or of viral
antigens in cerebral spinal fluid.
Influenza viruses are responsible for most upper respiratory infections including pharyngitis. Common signs
and symptoms of influenza virus–associated pharyngitis
are fever, myalgia, and anorexia with conjunctivitis and
sore throat.2
BACTERIAL PHARYNGITIS
Etiology and Epidemiology
Approximately 30% of all pharyngitides have a bacterial etiology.3 Infection with GABHS is the most common cause of bacterial pharyngitis and is responsible
for approximately 5% to 15% of adult cases and up to
50% of pediatric cases that require antimicrobial treatment.14 – 16 GABHS are gram-positive organisms that
grow in culture as pairs or chains of variable length.
They are categorized by their hemolytic ability (eg, the
complete lysis of erythrocytes15 on sheep blood agar)
and by the Lancefield (Group A) classification, which is
based on differences in the chemical structure and
immunologic specificity of the polysaccharide cell
wall.14 The virulence of GABHS is associated with the
M protein located on the polysaccharide cell wall and
with the production of biologic products, including
streptolysin O and S and streptokinase. These virulence
factors enable the body to mount an immune response
against the bacteria. However, the overall importance of
GABHS does not exclude other bacterial causes of
pharyngitis such as groups C and G β- hemolytic streptococci, Neisseria gonorrhoeae, Mycoplasma pneumoniae,
There is no single
pathognomonic sign or
symptom that is diagnostic
of infection with GABHS.
Chlamydia species, and Arcanobacterium haemolyticum
(Table 3).
Throat infections caused by GABHS produce a selflimited, localized inflammation of the tonsillopharynx
that generally lasts 3 to 5 days.15 GABHS adhere to the
mucosa of the oropharynx and the nasopharynx of
infected persons and are spread via person-to-person
contact with infectious nasal or oral secretions.
Transmission most commonly occurs in schools14 (and
other places where there is crowding) and during the
winter. Pharyngitis caused by infection with GABHS can
occur at any age but is rare before age 2 years and most
common at age 5 to 11 years.16 The incidence then
decreases with age, most likely because increased exposure to the organism over time provides immunity.15
Diagnosis
Clinical evaluation. Results of physical examination
can suggest a bacterial etiology of pharyngitis, but the
findings of tonsillar exudates, lymphadenopathy, and
fever are unfortunately not specific for bacterial pharyngitis. Again, in eliciting patient history, clinicians should
collect data on the onset, progression, and severity of
the sore throat, as well as on streptococcal exposures
(Table 5).
Approximately 8% to 40% of children and approximately 5% to 9% of adolescents15 who have the classic
symptoms of pharyngeal erythema and swelling, patchy
tonsillar exudates, anterior cervical lymphadenopathy,
and (occasionally) fever are infected with GABHS; the
majority of other cases in these age groups are viral in etiology. Because most affected patients go to their physicians reporting various nonspecific symptoms, clinicians
are compelled to base the initial diagnosis of infection
with GABHS solely on clinical judgment, which has a
low specificity.17,18 There is no single pathognomonic
sign or symptom that is diagnostic of infection with
GABHS. Patients with recurrent episodes of sore throat
can alert physicians to resistant strains of GABHS and to
the possibility of their being carriers of GABHS.19,20
Infection with GABHS is important clinically
because of the acute morbidity associated with it and
Family Practice Volume 4, Part 4 5
Pharyngitis
Table 5. Common Symptoms, Signs, and Other
Factors Associated with GABHS Pharyngitis
Classically suggestive symptoms
Abdominal pain
Lack of cough
Lack of rhinorrhea and congestion
Sore throat
Classically suggestive physical signs
Anterior cervical lymphadenopathy
Edematous uvula
Fever
Leukocytosis
Petechial palate
Pharyngeal erythema and swelling
Scarlatiniform rash (may not be present)
Strawberry tongue
Tonsillar exudates-patchy
Classically suggestive other factors
Diabetes mellitus
History of GABHS infection (within 1 year)
Prior rheumatic fever
Seasonal influences (ie, November through December and
April through May)
Streptococcal exposure
GABHS = group A β-hemolytic streptococcal.
because it can lead to the nonsuppurative sequelae of
ARF and poststreptococcal glomerular nephritis.14 As a
result, clinicians sometimes tend to overdiagnose sore
throat as being caused by infection with GABHS, leading to the unnecessary prescription of antibiotics. To
avoid this potential problem, many investigators have
developed scoring systems to help physicians maximize
their diagnostic accuracy.17,21,22
In an evidence-based medicine article on pharyngitis,
McIsaac and colleagues17 found 4 signs that independently predicted a positive throat culture in patients infected with GABHS who were age 15 years and older:
(1) tonsillar exudate, (2) swollen anterior cervical lymph
nodes, (3) lack of cough, and (4) a history of a temperature greater than 100.4°F (38°C). This study predicted
that, in persons age 15 years and older living in a community not endemic for GABHS and having none or
only 1 of the above-mentioned signs, the probability of
infection is less than 10%.17 In this case, the physician
should neither obtain a throat culture nor treat the
6 Hospital Physician Board Review Manual
patient. If 2 to 3 of these signs are present, a throat culture is indicated as is treatment, if the culture is positive
for GABHS. If all 4 signs are present in a patient who lives
in a nonendemic area, immediate throat culture and
treatment are recommended.
The difficulty in using this and other scoring systems
to diagnose infection with GABHS clinically in patients
who have sore throats lies in the fact that there is no single sign or symptom (or even combination of signs and
symptoms) that is absolutely diagnostic of the infection.
To illustrate this fact, investigators tested a different
scoring system in children that identified 6 factors most
likely associated with GABHS pharyngitis3: (1) age 5 to
15 years, (2) occurrence during November through
May (“GABHS season”), (3) pharyngitis (eg, erythema,
exudates or swelling), (4) temperature greater than
101°F (38.3°C), (5) tender cervical nodes larger than
1 cm in diameter, and (6) the absence of coryza, cough,
conjunctivitis, and other findings typical of viral infections. However, this system had a positive predictive
value of only 75% in children having all 6 factors.3
Other β-hemolytic streptococci (eg, group C and G)
can cause an infection resembling that associated with
GABHS. However, the course of these infections is selflimited, and ARF is not associated with any β-hemolytic
infection other than group A.3,23,24 In adolescents, a history of orogenital contact also can signal the possibility of
gonococcal pharyngitis. Some of the associated clinical
findings include sore throat with urethritis or vaginitis
and exudative tonsillar pharyngitis. In addition, pharyngitis caused by the atypical bacterium Mycoplasma pneumoniae can be associated with pneumonia and laryngitis
and can cause findings of headache, fever, sore throat,
prolonged cough, bronchitis, and bullous myringitis. Infection with Arcanobacterium haemolyticum is uncommon
in the United States; seen mostly in adolescents and
young adults, this infection has initial signs and symptoms similar to those of infection with GABHS but produces negative results on throat culture.15,23,25
Throat culture. Throat culture remains the gold standard in laboratory testing for confirmation of the diagnosis of pharyngitis caused by infection with GABHS.
The throat culture is simple to perform and inexpensive. To maximize accuracy, both the tonsillar region and
posterior pharyngeal wall should be swabbed. The resultant specimen should then be inoculated onto a 5%sheep-blood agar plate to which a bacitracin disk is
applied. Throat cultures for GABHS have a reported
sensitivity of 97% and a specificity of 99%.15 There are,
however, 2 problems encountered in using results of
throat culture to diagnose infection with GABHS, namely the difficulty of ensuring proper sampling techniques
Pharyngitis
and the element of time. Results of throat culture are seldom available before 24 hours have passed.3,5,15
Rapid streptococcal antigen detection. Another diagnostic modality that can be used in cases of suspected
infection with GABHS is the rapid streptococcal antigen detection test, a method developed in the 1980s.
This test works by extracting the group A antigen from
the carbohydrate segment of the cell wall of bacteria
and then demonstrating its presence by an immunologic reaction. A study evaluating the average sensitivity
and specificity of this rapid detection test in offices and
hospitals revealed a range for sensitivity of 79% to 87%
and for specificity of 90% to 96%.15 Therefore, if the test
is positive for GABHS, the patient should receive antibiotic treatment, given the test’s high rate of specificity.
Clear advantages of the test include its ease of use and
rapidity, with results available within minutes; however,
the test is more expensive and less accurate than are
results of throat cultures.
If a rapid streptococcal antigen detection test is negative for GABHS in a patient suspected of having the
infection, a throat culture should be performed. If the
throat culture or the rapid streptococcal antigen detection test is positive for GABHS, the patient should be
treated. If neither is positive for GABHS in patients
with pharyngitis, every effort should be made not to
use antibiotics. The development of a good providerpatient relationship is likely to be useful when deciding
against antibiotic treatment; in the case of children or
adolescent patients, timely follow-up and close communication with the parents or care providers are necessary to ensure their understanding that negative
results on throat culture mean that no antibiotic treatment is necessary.
OTHER TYPES OF PHARYNGITIS
Six common other causes of pharyngitis should be
considered when viral and bacterial pharyngitis have
been ruled out, namely allergies, irritation (by an environmental insult or a foreign body), overuse of the
voice, and trauma.5 History and physical examination
are critical in the evaluation of these possible other etiologies of pharyngitis (Table 4).
Allergic pharyngitis occurs seasonally and is associated with oropharyngeal and conjunctival pruritus. Fever
and adenopathy are generally absent. Irritative pharyngitis generally evolves from dry and irritated pharyngeal
mucosa, leading to a sore throat. This condition usually
occurs in winter, especially when hot-air heating is used,
and with exposure to such factors as cigarette smoke,
hot foods, and acids or lye. Swallowing a foreign body
such as a fish bone or small toy can elicit similar symptoms and require further diagnostic investigation before
the cause is discovered.5 Hoarseness is usually found in
cases of overuse of the voice or of viral laryngitis and can
be accompanied by cough and sore throat. Patient history and laryngoscopic examination are helpful in
determining the diagnosis.
In the examination of adults who have pharyngitis, a
thorough social and occupational history should be
elicited. Patients involved in particular industries, especially those using aniline dyes, and in woodworking
merit special attention because of their increased risk
for oropharyngeal cancers.5
MANAGEMENT OF PHARYNGITIS
VIRAL PHARYNGITIS
In managing pharyngitis, the provider’s task is to
accurately diagnose the type and provide appropriate
treatment, with judicious use of antibiotics when needed. As indicated previously, antibiotics are not effective
pharmacologic treatment for viral pharyngitis. Instead,
management of viral pharyngitis generally involves supportive measures. Recommendations to patients with
the disorder should include rest and intake of fluids; the
use of acetaminophen and other analgesics for symptomatic relief also should be recommended. Adult patients should be encouraged to gargle with warm saline
frequently and use throat lozenges for symptomatic
relief. Caution is advised regarding throat lozenges in
younger patients because of the risk for choking. Most
pediatricians strongly advise against the use of either
products with viscous lidocaine or topical anesthetic
sprays in patients younger than 5 years because of the
possibility of systemic absorption; in the very young,
aspiration is a definite hazard.1
Treatment of infectious mononucleosis includes supportive therapy, recommendation of a soft diet, and use
of analgesics (ibuprofen, acetaminophen). Aspirin in
young children is not recommended because of the risk
for Reye’s syndrome. Antibiotics are not indicated for the
treatment of infectious mononucleosis; in fact, amoxicillin and ampicillin produce a classic pruritic, maculopapular rash in 90% of patients with this disease.12 To
prevent dehydration, clinicians should strongly recommend liberal intake of fluids. In patients with splenomegaly, caution against participation in contact sports for
approximately 4 to 6 weeks is appropriate to avoid possible splenic rupture and other complications.
Family Practice Volume 4, Part 4 7
Pharyngitis
BACTERIAL PHARYNGITIS
Treatment of Group A β-Hemolytic Streptococcal
Pharyngitis
Infection with GABHS, if left untreated, runs a course
of approximately 1 week. The reasons to treat the disease
include minimizing discomfort, preventing contagion,
and preventing suppurative and nonsuppurative complications. Suppurative sequelae of infection with GABHS
include pharyngeal and peritonsillar abscesses; the chief
nonsuppurative complication is ARF, which can affect the
heart, joints, and central nervous system. ARF is still the
leading cause of cardiovascular morbidity and mortality
worldwide.3 Acute poststreptococcal glomerulonephritis,
another nonsuppurative complication, is not preventable
by administration of antibiotics because its origins are primarily immunologic in nature. When results of throat culture show other streptococcal organisms (eg, groups B
and C), treatment is not recommended because infection with these organisms does not have the same sequelae as infection with GABHS.
The pharmacologic agent of choice to treat
pharyngitis resulting from infection with GABHS is
penicillin V.19,20,25,26 The recommended dose in children is 250 mg, 2 to 3 times daily, for a full 10-day
course. To increase the delivery of the antibiotic agent
in salivary secretions over the tonsillar area and to
enhance compliance in children, amoxicillin also can
be used (flavored pediatric suspensions are available).1,25,26 The adult dose of penicillin or amoxicillin
is 500 mg, 2 to 3 times daily, for 10 days.25,26 For
patients allergic to penicillin, the antimicrobial agent
of choice is erythromycin, administered over a 10-day
course (eg, estolate 20 to 40 mg/day or ethylsuccinate
40 mg/kg body weight, 2 to 4 times daily).19,20,25,26
Sulfonamides, trimethoprim, tetracyclines, and thirdgeneration cephalosporins are not appropriate therapeutic agents in the treatment of pharyngitis caused
by infection with GABHS.
Although a 10-day course of penicillin or amoxicillin is
the classic treatment recommendation, other drugs have
been approved by the US Food and Drug Administration
to treat pharyngitis caused by infection with GABHS that
are equally effective, in less time.25–27 These drugs include
penicillin G benzathine, azithromycin, cefpodoxime proxetil, and cefuroxime axetil. Penicillin G benzathine is especially useful for patients who are noncompliant and either
have a family history of rheumatic fever or live in crowded
conditions that place them at high risk for transmitting
GABHS. Parenteral use of penicillin is not the standard of
care in the United States for treating pharyngitis caused by
infection with GABHS because of the higher risk of anaphylaxis, compared to oral use.1,25,26
8 Hospital Physician Board Review Manual
Penicillin G benzathine, when necessary, should be
given as a single injection in a large muscle mass. This
injection can be quite painful. The recommended dose is
600,000 U for patients weighing less than 27 kg (60 lb)28
or 1,200,000 U for patients weighing more than 27 kg.
Azithromycin (12 mg/kg daily) can be given for a 5-day
course, with a maximum dosage of 500 mg daily, and cefpodoxime proxetil can be given in a dosage of 10 mg/kg,
twice daily, for 5 days.29 However, a regimen involving
administration of either macrolide antibiotics or cephalosporins is more costly and has more adverse effects, even
though these agents have a broader spectrum of coverage.19,20,25,26
Recurrence of Group A β-Hemolytic Streptococcal
Pharyngitis
The recurrence of pharyngitis caused by infection
with GABHS involves several factors, the most common
being nonadherence to the recommended 10-day penicillin/amoxicillin regimen. In a recent review of articles
discussing patients’ adherence to physicians’ instructions in cases of streptococcal pharyngitis,20 one of the
studies mentioned examined adherence to regimens
involving oral penicillin preparations. The authors concluded that the most common reason (37%) for nonadherence was patients’ impressions that they were well
and no longer needed the medication. Other reasons
included carelessness (27%), insufficient funds to buy
the medication (17%), refusal to swallow tablets (11%),
and misunderstanding of the instructions (8%).20 The
primary care provider must also consider reinfection as
a cause of recurrence of this type of pharyngitis.7,23
Schools, homes with large families, crowded work
places, and day-care environments create settings that
are conducive to the transmission of GABHS. Close contacts of the patient may require throat cultures and treatment to eradicate the infection that spreads by a “pingpong” effect in families.
Some studies have suggested that neighboring
β- lactamase–producing upper respiratory tract flora
might produce drug resistance in vivo in GABHS that
are drug sensitive in vitro, a phenomenon known as
indirect pathogenicity.7,15 Because this hypothesis remains
controversial, however, initial antibiotic therapy directed against these organisms is not recommended.
The presence of cocolonizing bacteria in the throat
(termed copathogens) that elaborate β- lactamase in the
tonsillopharynx also has been proposed as a possible
mechanism by which penicillin is inactivated in vivo and
stripped of its bactericidal action on GABHS.7,15 According to this theory, recurrences of infection (documented by throat culture) that are caused by colonization
Pharyngitis
Is infection with GABHS suspected
as the cause of the pharyngitis?
Yes
Rapid strep test
Negative
Positive
Treat with penicillin
Positive
Culture
Negative
Patient improves?
Yes
Follow the patient
(DO NOT TREAT)
No
No further
treatment
No
Culture and reevaluate
Treat with an antibiotic
with β-lactam activity
ENT referral
No
Patient improves?
Patient improves?
Yes
Yes
No further
treatment
Figure 1. Algorithm illustrating appropriate treatment of group A β-hemolytic streptococcal pharyngitis. ENT = ear, nose, and throat;
GABHS = group A β-hemolytic streptococci; Rapid strep test = rapid streptococcal antigen detection test.
with copathogens and are seen after failed treatment
for pharyngitis associated with GABHS (eg, following
ineffective penicillin therapy) should then be treated
secondarily with one of the following: a β- lactam antibiotic (such as amoxicillin-clavulanate), a first- or secondgeneration cephalosporin, clindamycin, or a secondgeneration macrolide (Figure 1). All of these secondary
regimens have a wider spectrum of antimicrobial activity, have more adverse effects, and are more costly
than is penicillin.5,20 The proposed copathogens include Staphylococcus aureus, Haemophilus influenzae,
Moraxella catarrhalis, and β- lactamase–producing bacteria that are common flora of the tonsillopharynx.7,15
Asymptomatic patients without history of rheumatic
fever should not undergo another throat culture after a
course of appropriate antimicrobial therapy. At the conclusion of the recommended therapy, the throat cultures of some of these patients still might be positive for
GABHS although the patients themselves are asymptomatic. When a patient carries GABHS for several weeks,
the serum antibody reaction does not occur, and the
bacteria should no longer be considered dangerous to
that patient.5
Complications of Group A β-Hemolytic Streptococcal
Pharyngitis
As previously mentioned, complications of pharyngitis
caused by infection with GABHS include suppurative
sequelae, such as peritonsillar and retropharyngeal
abscesses, and nonsuppurative complications, such as ARF
(which can affect the heart, joints, and central nervous system) and poststreptococcal glomerulonephritis. Peritonsillar abscess, a soft-tissue space infection, is an unusual
complication that usually occurs subsequent to pharyngitis and tonsillitis. Symptoms of pain, odynophagia, difficulty swallowing oral secretions to the point of respiratory
distress, and trismus may or may not be present. On examination of patients with peritonsillar abscess, signs of peritonsillar tissue swelling and lateral displacement of the
uvula may be seen; a mass may or may not be present. A
computed tomography scan aids in identification of the
abscess; treatment usually involves penicillin therapy and
should include surgical drainage if there is any sign of respiratory compromise.30
ARF is still the leading cause of cardiovascular morbidity and mortality worldwide3 and is associated with
strains of GABHS having the M-protein serotypes 1, 3,
Family Practice Volume 4, Part 4 9
Pharyngitis
PHARYNGITIS:
PATIENT EDUCATION MATERIALS
To assist clinicians in educating their patients about
pharyngitis, various materials, including pamphlets,
posters, and fact sheets, are available from the
Centers for Disease Control and Prevention. These
materials can be obtained free of charge by calling
404-639-4702; order sheets can be obtained via fax at
404-639-0817. The following Web sites also provide
useful information: http://www.cdc.gov/ncidod/dbmd/
antibioticresistance; www.aap.org (click on publications); and www.asm.org.
5, 6, 18, or 24—the so-called rheumatogenic strains.3,31
Poststreptococcal glomerulonephritis is associated with
the nephritogenic M-protein serotypes 12 and 49.3,31 Unlike ARF, poststreptococcal glomerulonephritis is not prevented by timely treatment of the immunologically inciting infection.
The syndrome of pediatric autoimmune neuropsychiatric disorders, which presents with symptoms of choreiform movements, obsessive-compulsive behavior, and
tic disorders, has been linked to infection with GABHS
and some viruses. An exact causal relationship, however,
has not been established. There is a postulated autoimmune etiology in the syndrome that is rare and occurs
primarily in boys (older than 3 years and especially at
puberty). Until more reliable information is available,
children with this syndrome should be closely monitored
and treated aggressively for infection with GABHS.32,33
OTHER CAUSES OF PHARYNGITIS
In a case clinically suggestive of gonococcal pharyngitis, intramuscular treatment with ceftriaxone should
be initiated pending results of cultures. The patient also
should be treated with azithromycin or doxycycline
because of the possibility of coinfection with chlamydiae.
CONCLUSION
CASE PATIENTS
Patient 1
Patient 1’s symptoms of sore throat accompanied by
rhinorrhea, cough, hoarseness, tonsillopharyngeal erythema, cervical lymphadenopathy, and absence of fever
most likely have a viral etiology. However, the presence
10 Hospital Physician Board Review Manual
of exudates and cervical lymphadenopathy also suggest
a bacterial (possibly a streptococcal) pharyngitis. Because Patient 1 has 2 of the 4 signs in the clinical scoring
for pharyngitis that predict infection with GABHS,17
throat culture is indicated, with treatment dependent on
the results. Given the patient’s age, gonococcal organisms and infectious mononucleosis are also possible
causes of his pharyngitis; the differential diagnosis for
this patient must include a viral cause, in light of the
patient’s signs of conjunctivitis and rhinitis.
A throat culture (the gold standard) using sheep
agar for detection of GABHS and Thayer-Martin medium for detection of gonorrhea (a DNA probe to detect
gonorrhea could also have been used) is ordered.
Other diagnostic tests include viral cultures, nasopharyngeal washings to isolate organisms, and a heterophil
antibody (Monospot) test. Until the results of the throat
culture are known, antibiotics are withheld. However,
the primary care provider reassures the patient and his
mother that the risk for possible harmful sequelae at
this time is virtually nonexistent and that antibiotics can
be prescribed later, if necessary (it would also have been
appropriate to give the mother a prescription at this
time with the instruction not to fill it unless she is
informed later that results of throat culture are positive
for GABHS). All results of diagnostic testing are negative for bacterial infection, and a diagnosis of adenoviral pharyngitis, which is often associated with keratoconjunctivitis, is made.
Patient 2
Patient 2 has classic signs of fever, tonsillar exudate,
and tender anterior cervical adenopathy in the absence
of cough, all of which are strongly suggestive of infection
with GABHS. The 4 criteria put forward by McIssac and
colleagues17 as indicating throat culture do not apply,
because they were developed for patients 15 years and
older and Patient 2 is only a 6-year-old child. However,
the presence of strawberry tongue and palatal petechiae
and the absence of congestion in this clinical setting are
highly associated with GABHS. The patient is treated
with penicillin (250 mg, 3 times daily), and a throat culture is obtained. When results of the throat culture come
back 24 hours later as positive for infection with GABHS,
the patient’s mother is informed and instructed to continue the penicillin for a full 10 days. Because the child
is now afebrile and has no abdominal discomfort, he is
cleared to return to school the following day.
SUMMARY
The evaluation, diagnosis, and optimal management of pharyngitis requires taking a complete history,
Pharyngitis
performing a thorough physical examination, being
aware of epidemiologic factors, and knowing the appropriate therapy based on etiology. Again, there is no
single pathognomonic sign or symptom that can accurately diagnose the type of pharyngitis.
4. Perkins A. An approach to diagnosing the acute sore
throat. Am Fam Physician 1997;55:131–8,141–2.
5. Middleton DB. Pharyngitis. In: Irons TG, Newton DA,
editors. Primary care. Vol 23: Clinics in office practice.
No 4: Community acquired respiratory infections in children. Philadelphia: Saunders; 1996:719–739.
BOARD REVIEW QUESTIONS
6. Middleton DB. An approach to pediatric upper respiratory infections. Am Fam Physician 1991;44(5 Suppl):
33S– 40S,46S– 7S.
1.
7. Pichichero ME. Group A beta-hemolytic streptococcal
infections. Pediatr Rev 1998;19:291–302.
2.
3.
Which of the following findings is NOT suggestive
of infection with group A β- hemolytic streptococci?
A. Anterior cervical lymphadenopathy
B. Cough
C. Fever
D. Headache
E. Sudden onset
What is the sensitivity of a single correctly performed
throat culture on a blood agar plate?
A. 60%
B. 70%
C. 80%
D. 90%
E. Greater than 95%
Which of the following drugs is NOT recommended for the treatment of group A β- hemolytic streptococcal pharyngitis?
A. Azithromycin
B. Cefadroxil
C. Erythromycin
D. Penicillin V
E. Tetracycline
ANSWERS
1.
2.
3.
B
E
E
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Copyright 2001 by Turner White Communications Inc., Wayne, PA. All rights reserved.
12 Hospital Physician Board Review Manual