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Pharyngitis
Michele Morrison BS RN CCRN
State University of New York Polytechnic Institute
Family Primary Health Care I
October 2016
What is pharyngitis?
• Inflammation of the pharynx
• “Sore throat”
• Can be infectious, does not have to be
(Dunphy, Winland-Brown, Porter, & Thomas, 2011)
Etiology
Caused by viral infection
Caused by bacterial infection
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• Group A beta hemolytic
streptococcus
• Gonorrhea
• Chlamydia
• Corynebacterium
• Diptheria
• Mycoplasma pneumoniae
• Pertussis
• Tonsillitis
Measles
Adenovirus (common cold)
Chickenpox
Croup
Influenza
Mononucleosis
HIV
Rhinovirus
Coronavirus
Cocksackie virus
Other cause:
• Second-hand smoke
• Kawasaki disease
(Martel & Cherney, 2015)
(Dunphy, Winland-Brown, Porter, & Thomas, 2011)
Pathophysiology
• Infective cause enters pharyngeal mucosa
• Inflammation
• Nasal secretions
(Dunphy, Winland-Brown, Porter, & Thomas, 2011)
Incidence
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11 million people annually
Adults 2x/year
Children 5x/year
40-60% viral
15% strep
10% strep in adults (once every 8 years)
20-30% strep in children (once every 4 years)
Increased occurrence during colder weather
(30%)
(Linder, Chan, & Bates, 2006)
Screening and Risk Factors
Screening
• Assess if high risk patient
for strep pharyngitis
• History of rheumatic fever
• Close contact with person
with history of rheumatic
fever
• AHRQ algorithm
• Modified Centor Score
(Clinical Alignment and Performance Excellence University of
Michigan, 2013)
(Karla, Higgins, & Perez, 2016)
Risk Factors
• Frequent cough
• Exposure to inhaled toxins
(exhaust, cleaning fluids)
• Illnesses that cause pharyngitis
• Environmental allergies
• Smoke
• Immunocompromised
• Increased stress
• Alcohol in excess
• Age (5-15)
(Dunphy, Winland-Brown, Porter, & Thomas, 2011)
(Bisno, Gerber, Gwaltney, Kaplan, & Schwartz, 2002)
(Clinical Alignment and Performance Excellence University of Michigan, 2013)
(Clinical Alignment and Performance Excellence University of Michigan, 2013)
Modified Centor Score
• http://www.mdcalc.com/modified-centorscore-for-strep-pharyngitis/
Clinical Findings
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Sore throat
Scratchy throat
Throat red
Throat edema
Throat white spots or exudate
Difficulty swallowing
Painful swallowing
(U.S. Department of Health and Human Services, 2013)
Clinical Findings
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Fever
Swollen tonsils
Tonsillar exudate
Anterior cervical lymphadenopathy
Cervical lymph node tenderness
• NO cough, conjunctivitis, rhinorrhea if bacterial
(U.S. Department of Health and Human Services, 2013)
(Vincent, Celestin, & Hussain, 2004)
Clinical Findings
Group A Streptococcus Pharyngitis
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Pharyngeal swelling
Tonsillar swelling
Petechiae on palate
Anterior cervical lymphadenopathy
(Vincent, Celestin, & Hussain, 2004)
Differential Diagnosis
VIRAL INFECTIONS
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Measles
Adenovirus (common cold)
Chickenpox
Croup
Influenza
Mononucleosis
HIV
Rhinovirus
Coronavirus
Cocksackie virus
(Martel & Cherney, 2015)
(Dunphy, Winland-Brown, Porter, & Thomas, 2011)
Differential Diagnosis
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BACTERIAL INFECTIONS
Group A beta hemolytic streptococcus
Gonorrhea
Chlamydia
Corynebacterium
Diptheria
Mycoplasma pneumoniae
Pertussis
Tonsillitis
(Martel & Cherney, 2015)
(Dunphy, Winland-Brown, Porter, & Thomas, 2011)
Social and Environmental
Considerations
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Humans only reservoirs for group A strep
Direct contact with infected person
Saliva, nasal discharge
2-5 day incubation
Crowded areas
Generally not infectious after 24 hours of
antibiotics
• Stay home until afebrile for 24 hours
(Centers for Disease Control and Prevention, 2016)
Laboratory Tests and Diagnostics
• Rapid antigen/rapid strep
• Throat culture
• Monospot test
(Vincent, Celestin, & Hussain, 2004)
Management
Pharmacological Treatment
Cough suppressant
Acetaminophen
Positive for Group A Strep
Antibiotics
(Centers for Disease Control and Prevention, 2016)
Management
Antibiotics for streptococcus pharyngitis
Penicillin V: Children 250 mg po 2-3 times/day x 10 days
Adults 250 mg po 4 times/day x 10 days
Amoxicillin: 50 mg/kg once daily x 10 days
Penicillin G: < 27 kg 600,000 units x 1 dose
> 27 kg 1,200,000 units x 1 dose
No reports of resistance to penicillin or amoxicillin
Resistance noted to azithromycin and clarithromycin
(Centers for Disease Control and Prevention, 2016)
Management
Antibiotic therapy with penicillin allergy
Cephelexin: 20 mg/kg/dose po BID max 500 mg/dose x 10 days
Cefadroxil: 30 mg/kg/dose (max 1 GM) po once daily x 10 days
Clindamycin: 7 mg/kg/dose po TID max 300 mg/dose x 10 days
Azithromycin: 12 mg/kg (max 500) po once daily x 5 days
Clarithromycin: 7.5 mg/kg/dose (max 250/dose) po BID x 10 days
(Centers for Disease Control and Prevention, 2016)
Management
Non-pharmacological Treatment
Warm salt-water gargle
Humidifier
Fluids
Rest
Hot tea with honey and lemon
(Linder, Chan, & Bates, 2006)
Treatment Guidelines
Viral
• Warm salt-water gargle
• Acetaminophen
Bacterial
• Antibiotics
Surgery may be indicated to
remove tonsils if associated
with chronic infection
Treatment Guidelines
Infectious Disease Society of America
Guidelines for initiating antibiotic therapy
Patients at high risk for Group A strep – rapid antigen
If rapid antigen positive – start antibiotics
If rapid antigen negative – throat culture
If throat culture positive – antibiotic therapy
(Bisno, Gerber, Gwaltney, Kaplan, & Schwartz, 2002)
Complications
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Rheumatic fever
Scarlet fever
Peritonsillar abscess
Glomerulonephritis
Infectious mononucleosis – airway obstruction
(Linder, Chan, & Bates, 2006)
Follow-up
• Worsening symptoms
• Symptoms do not resolve
• Recurrence
(Karla, Higgins, & Perez, 2016)
Counseling and Education
• Avoid triggers (smoking, alcohol, crowded
areas, contact with infected people)
• Take full course of antibiotics
• Use back-up contraception if on oral
contraception and antibiotics
• Incubation period 2-5 days
• Transmitted via saliva and nasal secretions
• Hand washing
(Centers for Disease Control and Prevention, 2016)
Consultation and Referral
• Laryngoscopy if recurrent
• ENT Consult if recurrent
(Vincent, Celestin, & Hussain, 2004)
Multiple Choice Questions
1. Which symptoms are associated with viral
infectious causes of pharyngitis?
A. cough, diarrhea, rhinorrhea
B. Tonsillar exudate
C. Anterior cervical adenopathy
D. Positive throat culture
Answer
A. cough, diarrhea, rhinorrhea
These are common symptoms associated with
viral pharyngitis.
The other choices are all associated with
bacterial pharyngitis.
Multiple Choice Questions
2. Which is not a common cause of pharyngitis?
A. Group A streptococcus
B. Anemia
C. Adenovirus
D. Cocksackie virus
Answer
B. Anemia
Anemia is not known to cause pharyngitis
Group A streptococcus is a common bacterial
cause of pharyngitis
Adenovirus and cocksackie virus are common
viral causes of pharyngitis
Multiple Choice Questions
3. What is the recommended first line treatment
for group A streptococcus pharyngitis?
A. Cephelexin
B. Azithromycin
C. Penicillin
D. Levofloxacin
Answer
C. Penicillin
Penicillin is the first choice for treatment of
group A streptococcus pharyngitis
Cephalexin and azithromycin are options if the
patient has an allergy to penicillin
Levofloxacin is not recommended for the
treatment of group A streptococcus pharyngitis
Multiple Choice Questions
4. Who is more likely to test positive for group A
streptococcus pharyngitis?
A. A 65 year old male with a cough and sore throat
B. An 8 year old female with a fever and sore
throat
C. A 35 year old female with a sore throat and is a
current every day smoker
D. A 3 year old male with a sore throat with white
patches on their tonsils
Answer
B. An 8 year old with fever and sore throat
Group A streptococcus pharyngitis is most common
in children 5-15 years and is associated with fever
Patients 65 years old are unlikely to have group A
strep and a cough is likely to have a viral cause
A 35 year old is less likely to have group A strep and
smoking is a cause of non-bacterial pharyngitis
Positive group A strep is rare in a 3 year old
Multiple Choice Questions
5. Which is a recommended treatment for
pharyngitis with presumed viral etiology?
A. Hot tea with honey and lemon
B. Antibiotics
C. Laryngoscopy
D. Surgery
Answer
A. Hot tea with honey and lemon
Supportive therapy is recommended for viral
pharyngitis
Antibiotics are not effective against viral
infections
Laryngoscopy and surgery are invasive and
would not be warranted for a viral pharyngitis
which is typically self-limiting
Multiple Choice Questions
6. What is the pathophysiology that causes
pharyngitis?
A. Pharyngitis is not real, patients report having a
sore throat to get out of work
B. An infectious agent invades the pharyngeal
mucosa causing irritation and inflammation
C. Pharyngitis is only associated with tobacco use
D. Pharyngitis is only associated with throat cancer
Answer
B. Pharyngitis is caused by an infectious agent
that invades the pharyngeal mucosa
Pharyngitis is a real diagnosis that is very
common
Tobacco and throat can cancer can increase the
incidence of pharyngitis but are not the only
cause
Multiple Choice Questions
7. Group A streptococcus pharyngitis has been
reported to have isolated strains resistant to
which antibiotic?
A. Penicillin
B. Azithromycin
C. Amoxicillin
D. Clindamycin
Answer
B. Azithromycin
Group A streptococcus pharyngitis is only known
to have strains resistant to azithromycin and
clarithromycin
Multiple Choice Questions
8. Which is a complication of untreated group A
streptococcus pharyngitis?
A. Typhoid fever
B. Yellow fever
C. Rheumatic fever
D. Cabin fever
Answer
C. Rheumatic fever
Rheumatic fever is a known complication of
untreated group A streptococcus
Group A streptococcus is not associated with
typhoid fever or yellow fever
Multiple Choice Questions
9. Which is not a risk factor for group A
streptococcus pharyngitis?
A. Age 5-15 years
B. Immunocompromised patient
C. Contact with person infected with group A
strep
D. Age 65 years and older
Answer
D. Age 65 years and older
The age group at highest risk for group A
streptococcus is 5-15 years
Immunosuppression and contact with people
infected with group A strep increase the risk of
becoming infected with group A strep
Multiple Choice Questions
10.Which is a screening tool that can be used as
a guide for testing and treatment of
pharyngitis?
A. Modified Centor Score
B. Pharyngeal Assessment Tool
C. Brown’s Sore Throat Measurement
D. Wagner’s Strep Swallow Assessment
Answer
A. Modified Centor Score
The Modified Centor Score was developed by Dr.
Centor as a tool to determine patients at high
risk for group A strep
The other choices are not recognized
assessment tools for pharyngitis
THANK YOU!
References
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Centers for Disease Control and Prevention. (2016). Pharyngitis (strep throat).
Retrieved from http://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html
Clinical Alignment and Performance Excellence University of Michigan. (2013).
Pharyngitis guidelines for clinical care: Ambulatory. Retrieved from
http://www.med.umich.edu/1info/FHP/practiceguides/pharyngitis/pharyn.pdf
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary
care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA:
F.A. Davis Company.
Karla, M. G., Higgins, K. E., & Perez, E. D. (2016). Common questions about
streptococcal pharyngitis. American Family Physician, 94(1), 24-31. Retrieved from
www.aafp.org/afp
Linder, J. A., Chan, J. C., & Bates, D. W. (2006). Evaluation and treatment of
pharyngitis in primary care practice. Journal of American Medical Association, 166,
1374-1379. Retrieved from www.archinternmed.com
References
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Martel, J., & Cherney, K. (2015). Pharyngitis. Retrieved from
http://www.healthline.com/health/pharyngitis
U.S. Department of Health and Human Services. (2013). Pharyngitis. Retrieved
from https://www.guideline.gov/summaries/summary/46947/pharyngitis
Vincent, M. T., Celestin, N., & Hussain, A. N. (2004). Pharyngitis. American Family
Physician, 69(6), 1465-1470. Retrieved from
http://www.aafp.org/afp/2004/0315/p1465.html