MANAGEMENT OF PHARYNGOTONSYLITIS

PRESENTED BY HASHIM A.I. RN, BNsc

INTRODUCTION

Pharyngotonsilitis is a common illness that accounts for 1% of primary care visits. Viral infections account
for an estimated 60% to 90% of cases of Pharyngotonsilitis. Bacterial infections are responsible for
between 5% and 30% of Pharyngotonsilitis cases, depending upon the age of the population and the
season. Highest prevalence in winter, and highest incidence in children between the ages of 4 and 7
years.The GABHS accounts for 5% to 10% of Pharyngotonsilitis in adults and 15% to 30% in children. Up
to 38% of cases of tonsillitis are because of GABHS. Up to 14% of deep neck infections result from
pharyngotonsillitis.

DEFINITION

Pharyngotonsilitis is a type upper respiratory tract infection and can be defined as an infection or irritation
of the pharynx and/or tonsils and is usually associate with pain.

CAUSES

The aetiology is usually infectious and can be cause by variety of pathogens as follows:

1. Viruses account for about 70%-85% of cases in children over 3 years and they include Rhinovirus,
Coronaviruses, Adenoviruses, Coxsackie A, Influenza, Parainfluenza and Herpes family viruses
2. Bacteria are responsible for 15%-30% of cases in childen, the most significant bacterial agent
causing Pharyngotonsilitis in both adults and children is GABHS infection (Streptococcus
pyogenes). Beta-hemolytic streptococci belonging to other groups (predominantly C and G) are
detected less frequently. Mycoplasma pneumoniae, Chlamydia pneumoniae, and
Arcanobacterium haemolyticus are other bacterial causes of pharyngotonsillitis, but these
pathogens are rare.
3. Other causes include Allergy, Trauma, Toxins an Neoplasia

PATHOPHYSIOLOGY

With infectious pharyngotonsillitis, bacteria or viruses may directly invade the pharyngeal mucosa,
causing a local inflammatory response. Some viruses such as Adenovirus cause inflammation of the
pharyngeal mucosa by direct invasion of the mucosa or secondary to suprapharyngeal secretions. Other
viruses such as rhinovirus cause pain through stimulation of the pain nerve endings by chemical mediators
such as bradykinin.

GABHS infections are characterized by local invasion of the pharyngeal mucosa and release of exotoxins
and proteases, the erythogenic exotoxins are responsible for the development of scarlatiniform rashes.
Secondary antibody formation because of cross reactivity may result in rheumatic fever and valvular heart
disease.

CLINICAL MANIFESTATIONS

Unfortunately, the clinical manifestations of GABHS and non-GABHS pharyngotonsillitis overlap quite a
bit.
Suggestive for GABHS
 Fever > 38º C (100.4° F)
 Tender anterior cervical nodes
 Enlarged, red tonsils +/- purulent exudate
 Palate petechiae
 Headache
 Abdominal pain, nausea and/or vomiting
 Scarlet fever rash
 Age 5-15 years
 Present in late autumn, winter or spring
 History of recent exposure
Suggestive for viral etiology
 Cough and coryza
 Scleral conjunctival inflammation("pink eye")
 Hoarseness
 Pharyngeal ulcerations
 Diarrhea
 Characteristic viral rash

CLINICAL DIFFERENTIATION OF GABHS AND VIRAL PHARYNGOTONSILLITIS

Although it is difficult to distinguish viral and bacterial causes of pharyngotonsilitis on the basis of history
and physical examinations, it is very important to differentiate so as to evaluate the likelihood of GABHS
and thus decrease the occurrence of acute rheumatic fever (ARF) which generally occurs 10–14 days after
onset of acute pharyngotonsillitis. Early treatment of GABHS also shortens the clinical course, can reduce
the risk of transmission. Depending on the results of clinical examination the decision is made about
microbiological diagnostics and antibiotic therapy (if GABHS pharyngotonsillitis is suspected) or about only
symptomatic treatment and no further diagnostics (if it suggests viral pharyngotonsillitis).
There are three clinical scales evaluating the probability of streptococcal pharyngotonsillitis: according to

Breese, Centor?s with McIssac modification and Welsh?s. Since Breese?s scale does not allow

streptococcal infection to be ruled out in patients with low risk and is based on the number of leukocytes

in the blood, the other two are much more useful in everyday clinical practice. Walsh?s scale, however,

has been verified only in adults. Therefore Polish Recommendations 2010 consider Centor/McIssac?s

scale to be the most useful one, since it may be used for both children and adults.

Centor//McIssac?s scale

Criteria Points

Temperature >380C 1

Absence of cough 1

Swollen, Tender anterior cervical nodes 1

Tonsillar swelling or exudate 1

Age 3-14 years 1

Age 14-44 years 0

45 years or older -1

Score of 0-1 (low likelihood of GABHS) therefore requires no further testing or antibiotics

Score of 2-3 (Moderate Likelihood of GABHS) requires culture or RADT and antibiotics only if result is

positive

Score of 4> (High likelihood of GABHS) treat empirically with antibiotics and perform culture or RADT

DIAGNOSIS

1. History and physical examinations

2. Laboratory studies that may be helpful include the following:

 Group A beta-hemolytic streptococcal rapid antigen detection test (preferred diagnostic method
in emergency settings)
 Throat culture (criterion standard for diagnosis of GABHS infection [90-99% sensitive])
 Mono spot (up to 95% sensitive in children; less than 60% sensitive in infants)
 Peripheral smear

3. Imaging studies generally are not indicated for uncomplicated viral or streptococcal
pharyngotonsillitis. However, the following may be considered:
  Lateral neck film in patients with suspected epiglottitis or airway compromise
 Soft-tissue neck CT if concern for abscess or deep-space infection exist

MANAGEMENT
Most cases whether viral or bacterial, are relatively benign and self limited and most clinical
manifestations resolve spontaneously in 3-4 days

Antibiotics for GABHS Pharyngotonsillitis

Antimicrobial therapy should be prescribed for individuals with symptomatic pharyngotonsillitis only after
the presence of GABHS in the throat has been confirmed by either throat culture or a rapid antigen
diagnostic test. In situations such as concurrent diagnosis of rheumatic fever or a past history of rheumatic
fever, antimicrobial therapy can be initiated while awaiting laboratory confirmation, provided that such
therapy is discontinued if the diagnosis of GABHS pharyngotonsillitis is not confirmed by a laboratory test.
Penicillin V (250mg/kg/dose)
Administered orally two or three times daily is the treatment of choice for prevention of acute rheumatic
fever. Penicillin is the drug of choice in those not allergic to penicillin and who can swallow pills
Amoxicillin (50mg/kg/dose)
Amoxicillin as a single daily dose (max 1 gram/day) for 10 days is as effective as penicillin V or amoxicillin
given multiple times per day for 10 days., Amoxicillin suspension is generally preferred due to significantly
higher compliance since penicillin suspension tastes salty/bitter
Benzathine Penicillin G (600,000 IU)
A single intramuscular injection of benzathine penicillin G has been shown to be slightly more efficacious
than oral penicillin V and ensures compliance. Also, this route can be very useful in children who present
with severe abdominal pain and vomiting along with their GABHS pharyngotonsillitis. It does, however,
produce a significant amount of pain at the injection site that may last a 2–3 days following injection and
also increase risk of anaphylaxis severity.
Cepahlexin (25–50 mg/kg/dose divided BID)
Narrow spectrum cephalosporins (such as cephalexin) are now recommended for those who cannot be
safely prescribed a penicillin. The cephalosporins are recommended for those who do not have immediate
type (type 1) hypersensitivity to beta-lactam antibiotics. They have the most activity against Gram-positive
bacteria and little activity against Gram-negative enteric organisms, so they are less likely to encourage
antibiotic resistance than the extended-spectrum cephalosporins.
CLINDAMYCIN (20 mg/kg/d divided TID (max 1.8 g/day))
Clindamycin is a reasonable choice for treating penicillin-allergic patients, especially if they have had
immediate (type 1) hypersensitivity to beta-lactam antibiotics.The extremely bitter taste of clindamycin
solution may lead to nonadherence to the prescribed course.
Azithromycin (12 mg/kg/d once daily x 5 days (max 500 mg) )
Newer macrolides or azalide (such as azithromycin) antibiotics may be used for penicillin-allergic patients.
When prescribing azithromycin, note that the dose is 12 mg/kg/day for 5 full days. These
medications can cause prolongation of the QT interval in a dose-dependent manner. Because macrolides
are metabolized extensively by cytochrome P-450, they should not be taken concurrently with inhibitors
of cytochrome P-450, such as azole antifungal agents, HIV protease inhibitors, and some selective
serotonin reuptake inhibitor antidepressants. The FDA issued a warning that azithromycin could cause
potentially fatal irregular heart rhythm in some patients. At-risk patients include those with a slower-than-
normal heartbeat, with potassium or magnesium deficiencies, and those using medications to treat
existing heart arrhythmia.
Erythromycin, which had been the preferred antibiotic for those allergic to penicillin in the past, has fallen
out of favor. Erythromycin is associated with substantially higher rates of GI side effects compared to the
other agents
Nursing Management:
Patient Education
Educating patients helps assure appropriate care during the current episode and appropriate use of health
care services in the future. Some points that may be relevant to communicate to patients are summarized
below.
Causes of sore throats.: The majority of sore throats are not caused by GABHS and do not benefit from
antibiotic therapy.
Symptomatic treatment.: Use of acetaminophen, salt water gargles and lozenges may be helpful. Eating
soft foods, drinks cool or warm beverages which ever is must soothing. Also, avoid acidic drinks or spicy
food. Non-steroidal anti-inflammatory drugs (NSAIDs) may also be helpful, but avoid use in patients with
heart disease or its risk factors as NSAID use increases overall risk of heart attack or stroke.
Throat cultures.: May take up to 2-3 days for results to be known, but the majority are positive within 24
hours.
Full antibiotic treatment.: Except for a 5 day course of azithromycin, all antibiotics need to be taken for
the entire 10 days to prevent the risk of acute rheumatic fever, even if you are feeling better before then.
Antibiotic side effects:. These may include rash, nausea, abdominal pain, and/or diarrhea.
When no longer contagious:. The incubation period for strep throat is several days. Patients are
considered noncontagious 24 hours after starting therapy.
Preventing rheumatic fever:. Therapy may be initiated as late as 9 days after onset of symptoms and still
be effective in preventing rheumatic fever.

Nursing Diagnosis
COMPLICATIONS
Bacteremia, Otitis Media, Meningitis, Mastoiditis, Cervical Lymphadenitis, Endocarditis, Peritonsilar
abscess formation, pneumonia, rheumatic fever and poststreptococcal glomerulornephritis
CONCLUSION
In summary, careful clinical examination of a patient with acute pharyngotonsillitis allows one only to

suspect streptococcal etiology. Such suspicion should be confirmed by RADT or culture before making the

decision about antibiotic therapy. Penicillin V for 10 days is currently the antibiotic therapy of choice.

Following such a strategy we can minimize inappropriate use of antibiotics and prevent increasing

bacterial resistance.

CHALLENGES IN AKTH

1. Overuse of antibiotics. Despite the low incidence of GABHS pharyngotonsillitis, it was observed that
approximately 75% of paediatric patients with acute pharyngotonsillitis are prescribed antibiotics.
Also worrisome, GABHS test was performed on only few of children with sore throats