Created: January 2003 Revised: 1/2005, 1/2007, 1/2009, 1/2011 Last Revision: February 2013

Acute Pharyngitis Guidelines

This clinical guideline provides assistance in interpreting medical coverage provided under HPN and SHL commercial, Medicaid and Medicare benefit plans. When making coverage determinations, the enrollee specific document must be referenced. The terms of an enrollee's document (e.g., Evidence or Certificate of Coverage (EOC/COC), Attachment A, Benefit Schedules and any attached Endorsements and Riders) may differ greatly. In the event of a conflict, the enrollee's specific benefit document(s) supersedes this clinical practice guideline. All reviewers must first identify enrollee eligibility, any federal or state regulatory requirements and the plan benefit coverage as outlined in the enrollees specific benefit document prior to use of this clinical practice guideline. Other Policies and Coverage Determination Guidelines may apply. HPN/SHL reserves the right, in its sole discretion, to modify its Protocols, Policies and Guidelines as necessary. This clinical practice guideline is provided for informational purposes. It does not constitute medical advice.

DESCRIPTION:

Pharyngitis, defined as inflammation of the pharynx, is one of the most common conditions encountered in office practice, accounting for 12 million office visits annually in the United States. The major causes of pharyngitis are viral agents including influenza, parainfluenza, coronavirus, rhinovirus, adenovirus, respiratory syncytial virus (RSV), herpes simplex virus (HSV), Epstein Barr virus (EBV) and the human immunodeficiency virus (HIV). The major treatable pathogen is Group A beta hemolytic streptococcus (GAS) and is responsible for 10% of adult and 15% of pediatric cases. This condition is characterized by one or more of the following symptoms: malaise, fever, headache, rash, dysphagia, pain in throat, and/or postnasal secretion. The major goal for the evaluation of patients with pharyngitis is to identify those with GABHS) pharyngitis in order to prescribe antibiotics to these patients and not to treat others inappropriately.

DIAGNOSIS: PHARYNGITIS with GROUP A BETA HEMOLYTIC STREPTOCOCC US (GABHS) INFECTION VS. VIRAL PHARYNGITIS

Pharyngitis w/GABHS infection: Viral Pharyngitis: Individual presents with: Individual must meet at least three of the four following Prominent Rhinorrhea Centor Criteria( resulting in 77% Cough accuracy) Hoarseness o Fever by history o Tonsillar exudates Conjunctivitis o Absence of cough Diarrhea o Tender anterior cervical Sore throat adenopathy Nasal congestion (Lymphadenitis) (Does not require antibiotics) Diagnosis is confirmed through a positive rapid antigen test, or group A streptococcal culture. Complications if left untreated may include scarlet fever, glomerulonephritis, rheumatic mycocarditis and local abscesses. Rapid antigen detection test (RADT) should be performed because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis except when overt viral features are positive Perform a rapid strep test on all pediatric patients presenting with a sore throat, since Streptococcal pharyngitis is more common in the pediatric population, Follow up with a throat culture if rapid strep test is negative. Initiate symptom management only if throat culture is negative. Stop antibiotics immediately when previously started if throat culture is negative.

GENERAL DIAGNOSTIC GUIDELINES

General:

Children:

Adults: Do not perform routine back-up throat cultures on adults with a negative rapid antigen detection test

TREATMENT FOR PHARYNGITIS

Localized/Home Treatment: Gargle with salt water. (1/4 teaspoon of salt per 8 ounce glass of water) Suck on throat lozenges, hard candy or ice. Eat soft foods. Drink cool beverages or warm liquids. Take acetaminophen or ibuprofen. Do not give aspirin to children or teenagers due to risk of Reyes syndrome. Apply topical treatment to oral pharynx.

Antibiotic Treatment: For Adults: Limit antibiotic treatment to those individuals who meet three to four of the Centor Criteria, or individuals who are diagnosed with pharyngitis based on positive test antigen test results or positive group A streptococcal culture results. For Children: Limit antibiotic treatment to those individuals who are diagnosed with pharyngitis based on a positive rapid antigen test, or group A streptococcal culture. Preferred Antibiotics: Treat with Penicillin, (usually 10 days) as the preferred antibiotic for the treatment of pharyngitis with GAS infection. There is no group A streptococcus strain resistant to GAS. Penicillin is 90% effective in eliminating strep infections and may be even more effective in preventing acute rheumatic fever (ARF). First generation cephalosporins should be the alternative treatment for penicillin-allergic individuals.

PATIENT EDUCATION

Educate patients, parents and caregivers on the following: o Prevention of the disease o Comfort measures o Treatment recommendations Instruct patient, parent or caregiver on the symptoms and when to call provider back if the symptoms worsen or if they persist beyond five to seven days. Provide information to patients, parents and caregivers about the risk of taking unnecessary antibiotics and antibiotic resistance.

This guideline is an educational tool to aid clinical decision-making. It is not a standard of care. The physician should adapt this guideline when clinical judgment so indicates.

Attachment A: Pharyngitis algorithm (Adapted from the Pharyngitis algorithm by the Institute for Clinical Systems Improvement) Patient has symptoms suggestive of pharyngitis.

Perform History/Physical. Collect specimen for the rapid strep test and backup culture. Positive Rapid stress test result. Negative Have symptoms improved within 48-72 hours? No Positive Strep culture result Negative Consider re-evaluation. Broad spectrum culture Mono testing, if appropriate Empirical antibiotic therapy Treat and Educate patient. Yes Complete treatment.

Educate on home remedies.

Consider strep culture

Educate on non-Group AB-hemolytic streptococcal (GABS) pharyngitis symptoms.

Yes

Continue with home care.

No Symptoms improved?

Consider re-evaluation Broad spectrum culture Mono testing, if appropriate.

REFERENCE PERSONS:
Bennett Mitchell MD, Adult Medicine, Southwest Medical Associates

REFERENCES: Institute for Clinical Systems Improvement (ICSI). Acute Pharyngitis. 1998 Aug (revised 2005 May). Centers for Disease Control and Prevention. Careful Antibiotic Use, Academic Detailing Sheets for Judicious Treatment: Summary for Otitis Media, Rhinitis, Sinusitis, Pharyngitis, Cough Illness/Bronchitis. Centers for Disease Control and Prevention. Adult Appropriate Antibiotic Use Summary: Physician Information Sheet (Adults). Centers for Disease Control and Prevention. Acute Pharyngitis in Adults: Physician Information Sheet (Adults). Centers for Disease Control and Prevention. Pharyngitis: Treat Only Proven GAS: Physician Information Sheet (Pediatrics). Cooper RJ, Hoffman JR, Bartlett JG, Besser RE, Gonzales R, Hickner JM, Sande MA. Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults: Background. Annals of Internal Medicine. March 20, 2001: 134:509-517. Dowell SF, Marcy SM, Phillips WR, Gerber MA, Schwartz, B. Principles of Judicious Use of Antimicrobial Agents for Pediatric Upper Respiratory Tract Infections. Pediatrics. 1998: 101:163-165. Denson MR. Viral pharyngitis. Seminar Pediatric Infectious Disease.1995: 6:62-68. Institute for Clinical Systems Improvement (ICSI) HealthCare Guideline: Diagnosis and Treatment of Respiratory Illness in Children and Adults. Second Edition January, 2008. Centers for Disease Control and Prevention (CDC): Acute Pharyngitis in Adults, Adult Appropriate Antibiotic Use Summary. Emergency Medicine 40 (4):35, 2008: How Serious is that Sore Throat? Institute for Clinical Systems Improvement (ICSI). Diagnosis and Treatment of Respiratory Illness In Children and Adults, Second Edition - January, 2008. Current Medical Diagnosis & Treatment 49th Ed. (2010): Pharyngitis & Tonsillitis at http://online.statref.com. UpToDate: Evaluation of acute pharyngitis in adults, January 2013. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, Martin JM, Van Beneden C. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012 Nov;55(10):e86-e102. [134 references] PubMed