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Running head: PHARYNGITIS
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Pharyngitis Treatment
Michele Morrison
State University of New York Polytechnic Institute
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Pharyngitis Treatment
The purpose of this paper is to discuss the different treatment options for pharyngitis, and
complications associated with incorrect treatment. Pharyngitis is a condition where the
pharyngeal mucosa becomes inflamed which leads to pharyngeal irritation and discomfort and is
commonly known as a “sore throat” (Renner, Mueller, & Shephard, 2012). This condition and
its treatment are both important for nurses and nurse practitioners to understand because it is a
very common condition and has serious complications if not correctly diagnosed or treated.
Etiology of Pharyngitis
Pharyngitis is diagnosed 11 million times each year in the United States (Linder, Chan, &
Bates, 2006) and it can have infectious or non-infectious causes (Martel & Cherney, 2015).
Infectious causes can be bacterial or viral (Chiappini et al., 2011). Common viral causes are
chickenpox, influenza, mononucleosis, Cocksackie virus, adenovirus (the virus that causes the
common cold) and measles (Martel & Cherney, 2015). Common bacterial causes include Group
A beta hemolytic streptococcus, tonsillitis, gonorrhea, chlamydia and pertussis (Martel &
Cherney, 2015). Non-infectious causes include smoking tobacco or exposure to second-hand
tobacco smoke, inhalation of other types of smoke such as during a fire, inhalation of other
toxins including household cleaning supplies and Kawasaki disease. Kawasaki disease is an
infectious cause of pharyngitis but it is not known if the disease is caused by a virus or bacteria
(Martel & Cherney, 2015). Another cause of pharyngitis is increased nasal secretions because
this can irritate the pharyngeal mucosa as well (Renner, Mueller, & Shephard, 2012). The
frequency of occurrence of this condition and the risks associated with improper treatment make
this a condition that is necessary for nurses and nurse practitioners to study to ensure proper
etiology identification in order to determine the correct treatment.
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Treatment of Pharyngitis
It is important to correctly identify the cause of pharyngitis because the cause will
determine treatment. Current guidelines recommend symptomatic treatment for non-bacterial
causes of pharyngitis and antibiotics for pharyngitis caused by bacteria (Centers for Disease
Control and Prevention, 2016). The first line antibiotic to treat Group A strep pharyngitis, which
is the most common bacterial cause of pharyngitis, is Penicillin (Chiappini et al., 2011). The
gold standard for diagnosing Group A streptococcus pharyngitis is with a throat culture.
Antibiotic therapy should not be initiated based on symptomology alone.
Complications of Inappropriate Treatment
Inappropriate identification of the cause of pharyngitis and/or lack of treatment or
inappropriate treatment can have serious risks and complications. The most common cause of
pharyngitis is a virus which account for approximately 2/3 of all cases of pharyngitis (Palla,
Khan, Gilani, & Marra, 2012). Palla (2012) discusses complications associated with improper
diagnosis and resulting improper treatment of pharyngitis including overprescribing of
antibiotics, which occurs when antibiotics are prescribed for pharyngitis of a non-bacterial cause.
This can lead to complications ranging from rhinitis to colostrum dificile and also includes
antibiotic resistance (Palla et al., 2012). This also leads to increased healthcare costs associated
with unnecessary antibiotic prescriptions (Carrillo-Marquez, 2016). Another complication of
inadequate treatment of pharyngitis results from improperly treating pharyngitis caused by
Group A streptococcus. Lack of treatment of this condition can lead to rheumatic fever (Linder
et al., 2006).
Method
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The method used for this literature review was systematic. Sources were electronic
databases including CINAHLPlus with Full Text, MEDLINE, and Cochrane Collection Plus.
Search terms included pharyngitis, sore throat, streptococcus, streptococcal pharyngitis,
tonsillitis, viral pharyngitis, and non-infectious pharyngitis. Selection criteria included articles
about treatment guidelines and complications of inadequate or incorrect treatment. Exclusion
criteria were sources more than 5 years old and articles that were not peer reviewed.
Literature Review
Treatment of Viral Pharyngitis
Most diagnoses of pharyngitis have a viral etiology (Harrist, Van Houten, Shulman, Van
Beneden, & Murphy, 2016) accounting for the cause of more than half of all cases of pharyngitis
(Cingi et al., 2011). The viruses that most commonly cause pharyngitis are the rhinovirus and
the adenovirus (Renner, Mueller, & Shephard, 2012). The guidelines do not recommend testing
for Group A Beta-hemolytic streptococci in patients that present with a likely viral etiology, for
example patients who present with a sore throat with other symptoms typical of a viral cause
including a cough or runny nose (Harrist et al., 2016). This testing results in unnecessary
medical costs. Treatment guidelines for viral infections recommend supportive treatment (Palla
et al., 2012). These supportive treatments should be aimed at the goal of reducing discomfort
and swelling of the pharyngeal mucosa such as topical anti-inflammatories and analgesics (Cingi
et al., 2011).
A viral infection that commonly causes pharyngitis is the rhinovirus which is often the
cause of the common cold. There are many treatment remedies for the symptoms associated
with the common cold ranging from homeopathic interventions to prescription medications
(Fashner, Ericson, & Werner, 2012). Interventions that have been shown to be effective are
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those that reduce coughing and inflammation because both of these conditions increase
pharyngitis (Cingi et al., 2011). Other interventions that are effective at relieving pharyngitis
include analgesic medications (Fashner et al., 2012).
Cingi et al (2011) researched the throat spray chlorhexidine gluconate and benzydamine
HCl and showed it to be effective at reducing pain and inflammation for patients with viral
pharyngitis. Vitamin D3 supplements can reduce the occurrence of influenza in children thereby
reducing the common associated symptom of pharyngitis, and vitamin C supplements can help
reduce pharyngitis symptoms (Setright, 2016).
Interventions that have not been shown to be effective at treating viral pharyngitis include
non-prescription cough suppressants, inhaled or oral steroids, nasal irrigation and Echinacea
(Fashner et al., 2012). Ibuprofen may relieve discomfort associated with pharyngitis but it can
actually prolong the underlying viral cause of the condition and it does not prevent the spread of
the viral infection to other people (Setright, 2016). It does, however, provide at least temporary
relief of symptoms (Renner, Mueller, & Shephard, 2012).
Treatment of Bacterial Pharyngitis
The most common bacterial cause of pharyngitis is Group A Beta-hemolytic streptococci
(GABHS) accounting for 20-30% of pharyngitis episodes (Block, 2014). The rates of
occurrence are higher in children with rates of approximately 37% in school aged children but
very rare in children less than 3 years old (Chiappini et al., 2011). The recommended treatment
for GABHS is antibiotics within 24-48 hours of symptoms (Palla et al., 2012). It is important to
note that the guidelines in some countries, such as the UK and Scotland, antibiotics are not
recommended for GABHS because they view this condition as typically self-limiting with the
risk of complications low (Chiappini et al., 2011).
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The first line antibiotic choice for treating GABHS is penicillin V 250 mg three times a
day for children, 4 times a day for adults, for ten days (Centers for Disease Control and
Prevention, 2016). Amoxicillin has equal effectiveness against GABHS and due to its once a
day dosing and better taste it is an acceptable antibiotic choice for children (Chiappini et al.,
2011). For patients with a true penicillin allergy the following antibiotics are recommended:
clindamycin, azithromycin, clarithromycin, cephalexin or cefadroxil (Centers for Disease
Control and Prevention, 2016).
There have been no isolated strains of GABHS that have shown
resistance to penicillin (Chiappini et al., 2011).
The most serious complications of GABHS are rheumatic fever and glomerulonephritis
(Chiappini et al., 2011). Prescribing antibiotics for this bacterial infection are recommended by
the World Health Organization (WHO) to prevent these complications as well as to prevent
suppurative complications (Chiappini et al., 2011) which include otitis media, lymphadenitis and
peritonsillar abscess (Block, 2014).
Antibiotic therapy is not recommended for patients who are asymptomatic carriers of
pharyngeal GABHS. The exception to this is in the incidence of or family history of rheumatic
fever or glomerulonephritis after streptococcal infection (Chiappini et al., 2011).
Treatment of Non-Infectious Pharyngitis
The list of non-infectious causes of pharyngitis is long and includes almost anything that
can irritate the pharyngeal mucosa including endotracheal intubation, air pollution, snoring,
inhalation of smoke or other hazardous chemicals and certain medications (Renner, Mueller, &
Shephard, 2012).
The first treatment in these cases would be to eliminate or reduce exposure to the trigger
whenever possible and if necessary treatment would consist of supportive therapy such as anti-
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inflammatories and analgesics. Exposure to cigarette smoke is a significant risk factor for
pharyngitis (Renner, Mueller, & Shephard, 2012). This is one of many reasons to promote
smoking cessation. Another modifiable risk factor for pharyngitis would be avoiding frequent or
excessive shouting (Renner, Mueller, & Shephard, 2012).
Pharyngitis is a common finding in the postoperative patient who required an artificial
airway; endotracheal intubation causes pharyngitis 28-45.5% of the time, possibly as high as
70% of the time (Renner, Mueller, & Shephard, 2012). This is much higher than patients whose
airway was maintained with a laryngeal mask airway during a procedure as these patients
develop pharyngitis 3.5-21.4% of the time (Renner, Mueller, & Shephard, 2012). Utilizing an
artificial airway cannot usually be avoided but it is important to know that the complication of
pharyngitis is higher with tracheal intubation compared to using a laryngeal mask airway.
There are also medications that can cause pharyngitis. It is important for the nurse
practitioner to be aware of these medications as they might need to be adjusted (if possible) for
the patient with chronic or recurrent pharyngitis. Examples of medications that can cause
pharyngitis are ACE-Inhibitors and chemotherapy medications (Renner, Mueller, & Shephard,
2012). Another type of medication that can cause pharyngitis is inhaled corticosteroids (Renner,
Mueller, & Shephard, 2012). In many situations, these medications cannot be removed from a
patient’s regimen and supportive therapy would be indicated.
Kawasaki disease, thyroid disease and gastroesophageal reflex disorder (GERD) can also
cause pharyngitis (Renner, Mueller, & Shephard, 2012). For the patient with pharyngitis as a
result of another illness or disease, it would be important to treat the underlying cause in addition
to treating with supportive therapy.
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Other treatment options for non-infectious pharyngitis include Chinese herbs in
conjunction with acupuncture and throat lozenges (Renner, Mueller, & Shephard, 2012).
Complications of Improper Treatment of Pharyngitis
Approximately 75% of patients diagnosed with pharyngitis are incorrectly prescribed
antibiotics (Palla et al., 2012).
Improper treatment of GABHS can have severe complications, most commonly
rheumatic fever and acute glomerulonephritis (Block, 2014). Other complications include
suppurative conditions of GABHS such as otitis media and sinusitis (Chiappini et al., 2011).
Although lack of antibiotic treatment for GABHS can have serious complications,
treatment of non-bacterial pharyngitis with antibiotics has its own issues.
Results
Summary of Findings
Study Limitations
Gaps and Controversies
Research gap: lack of studies testing effectiveness of chlorahex to treat strep
Conclusion
Summary
Themes and Contraindications of the Literature
Implications for Nursing Practice
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References
Block, S. L. (2014). Streptococcal pharyngitis: Guidelines, treatment issues, and sequelae.
Pediatric Annals, 43(1), 11-16. http://dx.doi.org/doi: 10.3928/00904481-20131223-04
Carrillo-Marquez, M. (2016). Bacterial pharyngitis treatment and management. Retrieved from
http://emedicine.medscape.com/article/225243-treatment
Centers for Disease Control and Prevention. (2016). Pharyngitis (strep throat). Retrieved from
http://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html
Chiappini, E., Regoli, M., Bonsignori, F., Sollai, S., Parretti, A., Galli, L., & De Martino, M. (2011).
Analysis of different recommendations from international guidelines for the
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Cingi, C., Songu, M., Ural, A., Yildirim, M., Erdogmus, N., & Bal, C. (2011). Effects of
chlorhexidine/benzydamine mouth spray on pain and quality of iife in acute viral
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Harrist, A., Van Houten, C., Shulman, S. T., Van Beneden, C., & Murphy, T. (2016). Notes from
the field: Group A Streptococcal Pharyngitis misdiagnoses at a rural urgent-care clinic--
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Linder, J. A., Chan, J. C., & Bates, D. W. (2006). Evaluation and treatment of pharyngitis in
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