ACUTE PHARYNGITIS

Pharyngitis is an acute infection of the oropharynx or nasopharynx.47 It is

responsible for 1%
to 2% of all outpatient visits.48 Although viral causes are most common,
group A β-hemolytic
streptococci (GABHS; also known as S. pyogenes), is the primary bacterial
cause47; pharyngitis due
to GABHS is commonly known as “strep throat.”
A new set of clinical practice guidelines for GABHS was published in
2012.47 These guidelines
provide “a systematic weighting of the strength of recommendation (e.g.,
‘high, moderate, low, very
low’) and quality of evidence (e.g., ‘strong, weak’)” using a well-known
rating system.29 Several of
the recommendations in these new guidelines differ substantially from
prior guidelines.
Epidemiology
Acute pharyngitis accounts for ~2 million emergency department and
outpatient department visits per
year,2 at a cost of approximately $1.2 billion total and up to $539 million
for children alone.49
Although viral causes are most common, GABHS is the primary bacterial
cause and is associated
with rare but severe sequelae if not treated appropriately.47,50
Nonsuppurative complications include
acute rheumatic fever, acute glomerulonephritis, reactive arthritis,
peritonsillar abscess,
retropharyngeal abscess, cervical lymphadenitis, mastoiditis, otitis media,
rhinosinusitis, and
necrotizing fasciitis.
Although all age groups are susceptible, epidemiologic data demonstrate
certain groups are at
higher risk. Children 5 to 15 years of age are most susceptible; parents of
school-age children and
those who work with children are also at increased risk. Pharyngitis in a
child younger than 3 years of
age is rarely caused by GABHS.47
Seasonal outbreaks occur, and the incidence of GABHS is highest in
winter and early spring.47
The incubation period is 2 to 5 days, and the illness often occurs in
clusters.51 Spread occurs via
direct contact (usually from hands) with droplets of saliva or nasal
secretions, and transmission is
thus worse in institutions, schools, families, and crowded areas.51
Untreated, patients with
streptococcal pharyngitis are infectious during the acute illness and for
another week thereafter.
Effective antibiotic therapy reduces the infectious period to about 24
hours.
Acute rheumatic fever is rarely seen in developed countries. In the United
States, acute rheumatic
fever secondary to GABHS infection was a cause of concern in the 1950s
and was the major reason
for penicillin therapy, but the annual incidence of this disease today is
extremely rare (≤1 case per 1
million population); however, some risk does remain. Outbreaks have been
reported in the United
States as recently as the late 1980s and early 1990s. Furthermore, acute
rheumatic fever is
widespread in developing countries.
Etiology
Viruses cause the majority of acute pharyngitis cases. Specific etiologies
include rhinovirus
(20%), coronavirus (5%), adenovirus (5%), herpes simplex virus (4%),
influenza virus (2%),
parainfluenza virus (2%), and Epstein-Barr virus (1%).47,52
A bacterial etiology is far less likely. Of all the bacterial causes, GABHS
is the most common
(10% to 30% of persons of all ages with pharyngitis) and is the only
commonly occurring form of
acute pharyngitis for which antibiotic therapy is indicated.47 In the
pediatric population, GABHS
causes 15% to 30% of pharyngitis cases. In adults, GABHS is responsible
for 5% to 15% of all
symptomatic episodes of pharyngitis.47
Other, less common causes of acute pharyngitis are groups C and G
Streptococcus,
Corynebacterium diphtheriae, Neisseria gonorrhoeae, Mycoplasma
pneumoniae, Arcanobacterium
haemolyticum, Yersinia enterocolitica, and Chlamydia pneumoniae.47
Treatment options for these
organisms are not addressed in this chapter.
Pathophysiology
The mechanism by which GABHS causes pharyngitis is not well defined.
Asymptomatic pharyngeal
carriers of the organism may have an alteration in host immunity (e.g., a
breach in the pharyngeal
mucosa) and the bacteria of the oropharynx may migrate to cause an
infection. Pathogenic factors
associated with the organism itself may also play a role. These include
pyrogenic toxins, hemolysins,
streptokinase, and proteinase.
Clinical Presentation
Sore throat is the most common symptom of pharyngitis. Accurate
differentiation of GABHS from
pharyngitis caused by other agents is important for treatment decisions;
however, this can be difficult
even for experienced clinicians. Therefore, microbiologic testing is
recommended for symptomatic
patients unless they have symptoms suggestive of viral etiology or are
younger than 3 years of age
(strong, high).47
In previous national guidelines, clinical scoring systems such as the Centor
criteria or
modifications of the Centor criteria have been advocated for clinical
diagnosis in adults as a way to
overcome the lack of sensitivity and specificity of clinician judgment and
to avoid laboratory testing
of all patients; however, recent guidelines from Infectious Disease Society
of America and the
American Heart Association suggest testing be done in all patients with
signs and symptoms of
streptococcal pharyngitis (strong, high).47 Only those with a positive test
for GABHS require
antibiotic treatment.47,53 Laboratory tests should not be performed unless
the patient has symptoms
consistent with GABHS pharyngitis. This is because a positive test does
not necessarily indicate
disease. A positive test may simply indicate that the patient is a carrier for
GABHS and is not
actively infected.
Approximately 20% of children are carriers; the prevalence is lower
among adults.47 Table 86–4
lists the evidence-based principles for diagnosis of GABHS. There are
several options to test for
GABHS. A throat swab can be sent for culture or used for the rapid
antigen-detection test (RADT).
Cultures are the gold standard, but they require 24 to 48 hours for results.
The RADT is more
practical in that it provides results quickly, it can be performed at the
bedside, and it is less
expensive than culture. If RADT is positive, it does not require a follow-
up throat culture (strong,
high).47 If RADT yields negative test results, it is generally recommended
to follow up with a throat
culture to confirm the results for children and adolescents but not
necessary in adults (strong,
moderate).47 Delaying therapy while awaiting culture results does not
affect the risk of complications
(although some argue that symptomatic benefit is postponed, and
contagion remains), and patients
must be educated as to the value of waiting, given the low false-negative
rate of RADT.53
TREATMENT
Desired Outcome
The goals of treatment for pharyngitis are to improve clinical signs and
symptoms, minimize adverse
drug reactions, prevent transmission to close contacts, and prevent acute
rheumatic fever and
suppurative complications, such as peritonsillar abscess, cervical
lymphadenitis, and mastoiditis.47
General Approach to Treatment
Once the diagnosis of GABHS pharyngitis has been made, the clinician
must decide appropriate
supportive care, when to initiate antibiotic therapy, the appropriate
antibiotic, and the duration of
therapy. The selection of appropriate antibiotic therapy will involve
careful consideration of cost,
safety, efficacy, potential for regimen adherence, and bacterial resistance
rates. Clinicians should be
aware of the local resistance patterns, which may differ from the national
patterns.
Antibiotic overuse has been well documented.47,52 Antibiotics are
prescribed for 73% of
patients who visit their provider with a complaint of “sore throat.”54 This
rate is well above the
incidence of GABHS pharyngitis. Antibiotic therapy should be reserved
for those patients with
clinical and epidemiologic features of GABHS pharyngitis, preferably
with a positive laboratory test
(strong, high). Empirical therapy is not recommended unless there is a
high index of suspicion based
on clinical or epidemiologic data and laboratory results are pending.
However, it is important to
discontinue empirical antibiotics if laboratory results are negative.
Nonpharmacologic Therapy
Supportive care should be offered to all patients with acute pharyngitis.
Little evidence is available
for nonpharmacologic therapy for pharyngitis. However, pharmacologic
supportive care interventions
include antipyretic medications, analgesics, and nonprescription lozenges
and sprays containing
menthol and topical anesthetics for temporary relief of pain (strong,
high).47 There are limited data
for use of corticosteroids to reduce the symptoms of GABHS pharyngitis
and given the risk of
adverse effects its use is not recommended (weak, moderate).47 Because
pain is often the primary
reason for visiting a physician, emphasis on analgesics such as
acetaminophen and nonsteroidal
antiinflammatory drugs to aid in pain relief is strongly recommended.
Pharmacologic Therapy
The most recent set of clinical practice guidelines was published by the
IDSA in 201247; these
guidelines are the primary source for many of the statements in this
chapter. Tables 86–5 and 86-6
outline dosing for acute GABHS pharyngitis and chronic carriers of
GABHS.
Antibiotics and Doses for Group A β-Hemolytic
TABLE 86-5

Streptococcal
Pharyngitis
For over 30 years, GABHS isolated in the United States have been
susceptible to penicillin,
with no reported cases of GABHS resistance to penicillin.47 Because
penicillin and amoxicillin have
narrow spectrums of activity and are readily available, safe, and
inexpensive, they are considered to
be the treatments of choice (strong, high).47,53 The only controlled studies
that have demonstrated that
antibiotic therapy prevents rheumatic fever following GABHS pharyngitis
were done with procaine
penicillin, which was later replaced with benzathine penicillin.53 Penicillin
given by other routes is
assumed to be equally efficacious. The ability of other antibiotics to
eradicate GABHS has led to
extrapolation that these antibiotics will also prevent rheumatic fever.53
Amoxicillin may be preferable for children with GABHS pharyngitis
because the suspension is
more palatable than penicillin.47 GI adverse effects and rash are more
common with amoxicillin. A
once-daily, extended-release formulation of amoxicillin has been approved
for treatment of GABHS
pharyngitis in adults and children aged 12 years and older; however, use of
once-daily dosing in
GABHS pharyngitis is not recommended by current guidelines.47
If patients are unable to take oral medications, intramuscular benzathine
penicillin can be given,
although it is painful.47 In penicillin-allergic patients, azithromycin,
clarithromycin, clindamycin, or a
first-generation cephalosporin such as cephalexin can be used if the
reaction is non–IgE-mediated
(strong, moderate).47,53 Newer macrolides such as azithromycin and
clarithromycin are equally
effective as erythromycin and cause fewer GI adverse effects; therefore,
these newer macrolides are
preferred to erythromycin. GABHS resistance to macrolides is low (5% to
8%) in the United States,
but is higher in some other areas of the world.47
In previous pharyngitis guidelines, clindamycin was only an alternative to
erythromycin-resistant
strains; however, it is now considered an acceptable alternative for
penicillin-allergic patients due to
the low GABHS resistance rate of 1%.47,53 Tonsillectomy is not
recommended because a Cochrane
review found that its impact on “sore throat” due to pharyngitis is
unpredictable (strong, high).55
GABHS resistance rates to tetracyclines are high. Sulfonamides and
trimethoprim–
sulfamethoxazole have poor eradication rates for GABHS; therefore, use
of these antibiotics is no
longer recommended.47 Fluoroquinolones are not recommended due to
poor activity of the older
agents. The newer fluoroquinolones have activity against GABHS but are
expensive and have a broad
spectrum of activity.47,53
The ideal time to start antibiotics has not been established. The immediate
start of antibiotics
does not affect the risk of developing rheumatic fever, and no evidence
suggests it reduces recurrent
infection.53 Clinical guidelines recommend withholding antibiotics unless
the patient has a positive
laboratory result.47,53 Nevertheless, a survey of clinicians treating children
and adolescents with
acute pharyngitis revealed that 42% of clinicians would start antibiotics
before diagnostic results
were received and many would continue antibiotics despite a negative test
result.56 A retrospective
analysis of visits to a primary care clinic for acute pharyngitis
demonstrated that 66% of providers
did not adhere to any of the recommended pharyngitis guidelines.54
The impact of appropriate antibiotic therapy is limited to decreasing the
duration of signs and
symptoms by 1 or 2 days.48 It can decrease the severity of pharyngitis
symptoms when initiated within
2 or 3 days of onset in patients with proven GABHS. Microbiologic
eradication will occur in 48 to
72 hours, which aids in decreasing transmission.48 The duration of therapy
for GABHS pharyngitis is
10 days, except for benzathine penicillin and azithromycin, to maximize
bacterial eradication (strong,
moderate).47 Although some clinicians have proposed shorter courses of
treatment for pharyngitis,
confounding factors from these studies, such as the lack of strict entry
criteria or differentiation
between new and failed infections, limit the widespread application of
short antibiotic courses at this
time.47
Approximately 25% of household contacts of a person with acute GABHS
pharyngitis harbor
GABHS in their upper respiratory tracts.47 Routine testing and/or treating
of asymptomatic household
contacts of an index patient is not recommended (strong, moderate).47
GABHS carriers do not need
antimicrobial therapy due to very low risk of spreading GABHS
pharyngitis or developing
suppurative or nonsuppurative complications.49 If tested, it is not necessary
to treat these
asymptomatic carriers. It is difficult to ascertain the cause of symptomatic
pharyngitis in carriers of
GABHS if they do develop symptoms. Providers should pay close
attention to the symptoms to help
differentiate viral versus bacteriologic cause of pharyngitis because
laboratory tests will be positive
in these patients (strong, moderate).47
Clinical Controversy…
A study explored the value of pharmacist-provided care for patients with
GABHS pharyngitis.
The study measured treatment costs and health outcomes in patients
diagnosed and managed by a
community pharmacist or usual care.57 Groups were compared in terms of
treatment costs
(excluding diagnostic costs) and quality-adjusted life days. The two
models scored similarly in
terms of quality-adjusted life days; however, the community pharmacist
provided care at a lower
treatment cost. The feasibility of pharmacist-directed care for patients with
GABHS pharyngitis
needs to be determined in additional studies involving larger populations.
When acute GABHS pharyngitis occurs in a carrier, a treatment course of
appropriate antibiotics
is recommended.47,53 In the treatment of recurring episodes of culture-
positive GABHS pharyngitis,
there are limited data to support a particular antibiotic regimen. Several
alternative antibiotics are
preferred over penicillin or amoxicillin with GABHS carriers and recurrent
pharyngitis.
Amoxicillin–clavulanate, clindamycin, penicillin/rifampin combination,
and benzathine penicillin
G/rifampin combination may be considered for recurrent episodes of
pharyngitis to maximize
bacterial eradication in potential carriers and to counter copathogens that
produce β-lactamases.47
Table 86–6 outlines dosing for eradication of GABHS in chronic carriers
and those who experience
symptomatic episodes.
Patients with documented histories of rheumatic fever (including cases
manifested solely by
Sydenham’s chorea) and those with definite evidence of rheumatic heart
disease should receive
continuous prophylaxis initiated as soon as the patient is diagnosed and the
initial infection has been
treated. The duration of secondary prophylaxis is individualized based on
patient risk of recurrence
of rheumatic fever and/or rheumatic heart disease. Intramuscular
benzathine penicillin G every 4
weeks is the recommended regimen for secondary prevention in the United
States in most
circumstances.53 Additional options for secondary prophylaxis include oral
penicillin V and
sulfadiazine. Medication adherence is critical for successful secondary
prevention with oral
antibiotics. Sulfadiazine is an effective antibiotic for the prevention of
infection and is appropriate if
the patient is penicillin-allergic. Sulfonamides are not appropriate for
treatment of GABHS
pharyngitis because they are not effective for eradication of GABHS. If
individuals are allergic to
penicillin and sulfadiazine, a macrolide or azalide is recommended;
however, this recommendation is
based on expert opinion rather than clinical trial data.53
Personalized Pharmacotherapy
Currently, there are no pharmacogenetic or genomic factors involved in
the diagnosis or treatment of
GABHS pharyngitis. Factors that should be considered when personalizing
therapy for a patient
include allergy status, prior antibiotic use, and adherence. Those with a
history of antibiotic use for
acne may be at higher risk for resistant strains of GABHS. Short-course
antibiotics or penicillin G
benzathine may be considered in patients with a history of nonadherence.
Evaluation of Therapeutic Outcomes
Most pharyngitis cases are self-limited; however, antibiotics hasten
resolution when given early for
proven cases of GABHS pharyngitis.47 Generally, fever and other
symptoms resolve within 3 or 4
days of onset without antibiotics; however, symptoms will improve 0.5 to
2.5 days earlier with
antibiotic therapy.47 Follow-up testing is generally not necessary for index
cases or in asymptomatic
contacts of the index patient47,50; however, throat cultures 2 to 7 days after
completion of antibiotics
are warranted for patients who remain symptomatic or when symptoms
recur despite completion of
treatment.53
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