CME Medical Practice

Antibiotic management of acute pharyngitis in

primary care
The Advisory Group on Antibiotic Stewardship Programme in Primary Care

ABSTRACT available clinical evidence, local prevalence of

pathogens and associated antibiotic susceptibility
The Centre for Health Protection of the Department of
Health has convened the Advisory Group on profiles, and common local practice.
Antibiotic Stewardship Programme in Primary Care
(the Advisory Group) to formulate guidance notes and
strategies for optimising judicious use of antibiotics Hong Kong Med J 2019;25:58–63
and enhancing the Antibiotic Stewardship Programme https://doi.org/10.12809/hkmj187544
in Primary Care. Acute pharyngitis is one of the most
common conditions among out-patients in primary The Advisory Group on Antibiotic Stewardship
Programme in Primary Care
care in Hong Kong. Practical recommendations on the
This article was diagnosis and antibiotic treatment of acute (Group members are listed at the end of the paper)
published on 31 Jan streptococcal pharyngitis are made by the Advisory
2019 at www.hkmj.org. Group based on the best Corresponding author: edmanlam@cuhk.edu.hk

Introduction antimicrobial resistance containment measures by not

The Government of the Hong Kong Special
Administrative Region attaches great importance to
the threat of antimicrobial resistance. Under the
authority of the Food and Health Bureau, and with
collaborative efforts from stakeholders, the Hong
Kong Strategy and Action Plan on Antimicrobial
Resistance (2017-2022) was established in July 2017.
Recommendations in six key areas and 19 objectives
were included in this Action Plan, aiming to slow the
emergence of antimicrobial resistance and prevent its
spread.
In connection with this Action Plan, the Centre
for Health Protection of the Department of Health
convened the Advisory Group on Antibiotic
Stewardship Programme in Primary Care (the
Advisory Group) comprising key stakeholders in the
public and private sectors, academia, and major
professional societies. Its objective is to formulate
guidance notes and strategies for optimising the
judicious use of antibiotics and enhancing the
Antibiotic Stewardship Programme in Primary Care
(https://www.chp.gov.hk/en/features/49811. html).
Guidance notes on antibiotic treatments for common
infections seen by primary care doctors have been
developed based on the best available clinical
evidence, local prevalence of pathogens and
associated antibiotic susceptibility profiles, and local
practice. Clinical evidence has mainly referred to
international practices, the latest guidelines from
international organisations, and systematic review
articles. In addition, simple information sheets for out-
patients are prepared to raise awareness and enable
them to use antibiotics appropriately. Primary care
doctors play an important role in
only practising rational antibiotic prescriptions but
also educating and engaging out-patients about the
safe use of antibiotics during clinical encounters.
Acute pharyngitis is the acute inflammation of
the oropharynx. It is characterised by sore throat and
pharyngeal erythema. It is one of the most common
conditions among out-patients in primary care in
Hong Kong.1,2
Acute pharyngitis is usually a benign, self-
limiting illness with an average length of illness of 1
week. It is often caused by respiratory viruses (eg,
rhinovirus, coronavirus, adenovirus, influenza virus,
parainfluenza virus, respiratory syncytial virus and
metapneumovirus). The other viruses of concern are
enterovirus, herpes simplex virus, Epstein-Barr virus,
cytomegalovirus, and human immunodeficiency virus
(HIV). Viral pharyngitis is a condition for which
antibiotics are not necessary. Out-patients with a sore
throat and associated symptoms and signs, including
conjunctivitis, coryza, cough, discrete ulcerative
stomatitis, hoarseness, diarrhoea, and viral exanthema,
are most likely to have a viral illness, such as common
cold, influenza, herpangina, and oral herpes.
Beta-haemolytic streptococci, particularly group
A Streptococcus (GAS), are the most common
bacterial pathogens of acute pharyngitis. Group A
Streptococcus is estimated to be responsible for
approximately 10% of cases of acute pharyngitis in
adults and 15% to 30% of those in children. 3 A local
study at an accident and emergency department in
Hong Kong showed that for those presenting with a
sore throat and without symptoms of common cold or
influenza, the prevalence rates of GAS pharyngitis

58 Hong Kong Medical Journal ©2019 Hong Kong Academy of Medicine. CC BY-NC-ND 4.0

were 2.65% in adults and adolescents aged >14 years and 38.6% in
children aged 3 to 14 years; none of the children aged
<3 years had GAS pharyngitis.4 Group A
Streptococcus pharyngitis can lead to suppurative (eg,
quinsy, otitis media, and other invasive infections)
and non-suppurative (eg, acute rheumatic fever,
poststreptococcal glomerulonephritis) complications.
However, acute rheumatic fever has not been
described as a complication of either group C
Streptococcus or group G Streptococcus pharyngitis.
Streptococcal pharyngitis is the most common form of
acute pharyngitis, in which antibiotic treatment is
indicated.
Diagnosis of acute streptococcal
pharyngitis
There are different recommendations on the
diagnostic strategy of acute streptococcal pharyngitis.
Ideally, to obtain a definitive diagnosis, out-patients
with symptoms and signs suggestive of a bacterial
cause (eg, sudden onset of fever, anterior cervical
lymphadenopathy, tonsillopharyngeal exudates)
should be tested for GAS with a rapid antigen
detection test (RADT) and/or throat culture. 5-8 A
negative RADT should be backed up by a throat
culture in children and adolescents, but not in adults.
Practically and clinically, different various clinical
scoring criteria have been developed to estimate the
likelihood of acute streptococcal pharyngitis, and we
recommend that practitioners make clinical decisions
about laboratory testing and/or antibiotic prescribing. 9-
11 The FeverPAIN score was developed in the primary
care setting in the United Kingdom in 2013. 12 The
Centor criteria were developed in the emergency
department setting in the United States in 1981; the
modified Centor criteria add age to the original Centor
criteria.13,14 The FeverPAIN score criteria are Fever
(during the previous 24 hours), Purulence (pus on
tonsils), Attend rapidly (within 3 days after onset of
symptoms), severely Inflamed tonsils, and No cough
or coryza; each of the criteria is worth 1 point
(maximum score of 5). A score of 0 or 1 is associated
with a 13% to 18% likelihood of isolating
Streptococcus. A score of 2 or 3 is associated with a
34% to 40% likelihood of isolating Streptococcus. A
score of 4 or 5 is associated with a 62% to 65%
likelihood of isolating Streptococcus. In contrast, the
modified Centor criteria are age 3 to 14 years, history
of fever (over 38°C), absence of cough, exudate or
swelling on tonsils, and tender/swollen anterior
cervical lymph nodes; each of the criteria is worth 1
point (maximum score of 5); note that 0 points are
assigned for age 15 to 44 years, whereas -1 point is
given for age ≥45 years. A score of -1, 0 or 1 is
associated with a 1% to 10% likelihood of isolating
Streptococcus. A score of 2 or 3 is associated with an
11% to 35% likelihood of isolating Streptococcus. A
score of 4 or 5 is associated with a 51% to 53%
Hong Kong Med J Volume 25 Number 1
# Antibiotic management of acute pharyngitis in primary care #
急性咽喉炎在基層醫療的抗生素治療
基層醫療抗生素導向計劃諮詢小組
衞生署衞生防護中心已召開基層醫療抗生素導向計劃諮詢小組，以製
訂優化合理使用抗生素及提升基層醫療抗生素導向計劃執行的指引和
策略。急性咽喉炎是香港基層醫療門診患者中最常見的病症之一。諮
詢小組根據現有最佳的臨床證據、本地病原體流行情況和相關的藥敏
測試結果以及本地常見做法，對急性鏈球菌性咽喉炎的診斷和抗生素
治療提出實用建議。
likelihood of isolating Streptococcus. There is
currently uncertainty about which clinical scoring tool
is more effective.
Based on the clinical experience that RADT is
not commonly available, and throat culture is time
consuming, requiring a 2- to 3-day turnaround time,
the Advisory Group agreed that using clinical scoring
criteria is preferential to not using any laboratory tests
or clinical scoring criteria, and the modified Centor
criteria are more widely and easily used (Table 1).
Antibiotic treatment of acute
streptococcal pharyngitis
Although the symptoms of acute streptococcal
pharyngitis resolve without antibiotic treatment, there
are arguments that justify antibiotic treatment for
acute symptom relief, prevention of suppurative and
non-suppurative complications, and reduction of
communicability. A recent systematic review on
antibiotics for sore throat found that the clinical
benefits were modest and required treatment of many
with antibiotics for one to benefit (the number of
people with sore throat who must be treated to resolve
the symptoms of one by day 3 was about 3.7 for those
with positive throat swabs for Streptococcus; 6.5 for
those with a negative swab, and 14.4 for those in
whom no swab had been taken).15 Antibiotic treatment
may shorten the duration of sore throat by 1 to 2 days.
Antibiotics may prevent complications of GAS
infection, including acute rheumatic fever or
suppurative complications.15 Out-patients are
considered no longer contagious after 24 hours of
antibiotic treatment. However, little evidence supports
the prevention of poststreptococcal
glomerulonephritis by antibiotic treatment.15
Although scarlet fever occurs throughout the
year, there has been a seasonal pattern in Hong Kong,
with higher activity observed from May to June and
from November to March in the past few years. 16
Scarlet fever is a bacterial infection caused by GAS,
and it classically presents with fever, sore throat, red
and swollen tongue (known as strawberry tongue),
February 2019 www.hkmj.org 59
 # The Advisory Group on Antibiotic Stewardship Programme in Primary Care #

TABLE 1. Modified Centor score

Criteria Score
Age range (Group A Streptococcus pharyngitis is rare under 3), years
3-14 +1
15-44 0
≥45 -1
Fever (temperature >38°C/100.4°F)
No 0
Yes +1
Cough
Present 0
Absent +1
Exudate or swelling on tonsils
No 0
Yes +1
Tender/swollen anterior cervical lymph nodes
No 0
Yes +1
Total score -1 or 0 1 2 3 4 or 5
Likelihood of acute streptococcal pharyngitis (%) 1-2.5 5-10 11-17 28-35 51-53

and erythematous rash with a sandpaper texture. It is
mainly a clinical diagnosis and can be treated by
appropriate antibiotics effectively.
After considering the benefits and risks (eg,
allergies and side-effects) of antibiotic treatment, the
Advisory Group agreed that antibiotic treatment is
indicated for out-patients presenting with a sore throat
and a modified Centor score of 4 or 5 and for out-
patients with positive laboratory results or certain
special reasons (eg, clinical scarlet fever, household
contact with scarlet fever, or known rheumatic heart
disease) [Table 2].
Oral penicillin V or amoxicillin are the
recommended antibiotics of choice for out-patients
who are not allergic to these agents. Resistance of
GAS to penicillins and other beta-lactams has not
been reported.17 First-generation cephalosporins (eg,
oral cephalexin) are the first-line agents for out-
patients with penicillin allergies who are not
anaphylactically allergic. Other cephalosporins (eg,
oral cefaclor, cefuroxime) are alternatives, but they
are not favoured as the first-line agents because of
their broad spectrum of activity. Resistance of GAS to
macrolides (eg, oral azithromycin, clarithromycin,
erythromycin) is known to be common in Hong Kong.
Erythromycin-resistant isolates of GAS are regarded
as resistant to clarithromycin and azithromycin as
well.17 According to data from the Microbiology
Division of the Public Health Laboratory Services
Branch of the Centre for Health
Protection, which undertakes bacterial isolation and
antibiotic susceptibility testing in public and private
out-patient settings in Hong Kong, the erythromycin
resistance rates of beta -haemolytic streptococci (in
which GAS contributed to majority of them) in throat
swab specimens has risen to 59.1% in the last few
years.18 Studies have shown that the erythromycin
resistance rates of GAS isolates were 4% in the
United States, 3.2% in France, 32.8% in Spain, and
65% in Taiwan.19-22 Respiratory fluoroquinolones (eg,
oral levofloxacin) are active against GAS, but they
have an unnecessarily broad spectrum of activity and
are not recommended for routine treatment of acute
streptococcal pharyngitis.6 Excessive use of
respiratory fluoroquinolones may lead to delay in the
diagnosis of tuberculosis and increased
fluoroquinolone resistance among Mycobacterium
tuberculosis in Hong Kong.23 Trimethoprim-
sulfamethoxazole should not be used because it does
not eradicate GAS from out-patients with acute
pharyngitis.6
After considering the basic principle that
narrow-spectrum antibiotics should be used as the
first-line agents to treat an infection that is not life-
threatening, the Advisory Group agreed that oral
penicillin V, amoxicillin or cephalexin are the first-
line agents to treat acute streptococcal pharyngitis
(Table 2). Treatment with oral macrolides or
respiratory fluoroquinolones requires sound
justifications, including documented history of beta-

60 Hong Kong Med J Volume 25 Number 1 February 2019 www.hkmj.org

 # Antibiotic management of acute pharyngitis in primary care #

TABLE 2. Recommended antibiotic treatment of acute streptococcal pharyngitis*

Drug (route) Dosage and frequency, Dosage and frequency, children Duration Remarks
adult (usual) (usual) (usual)
First line
Penicillin V (oral) 500 mg 2 to 4 times daily If ≤27 kg: 250 mg 2 to 3 times daily 5-7 days†
If >27 kg: 500 mg 2 to 4 times daily
Amoxicillin (oral) 1000 mg once daily or 50 mg/kg (maximum = 1000 mg) once 5-7 days†
500 mg 2 to 3 times daily daily or 25 mg/kg (maximum = 500 mg)
2 to 3 times daily
Cephalexin (oral) 500 mg 2 to 4 times daily 20 mg/kg (maximum = 500 mg) 2 to 4 5-7 days† • Cephalosporins should be avoided
times daily in individuals with immediate
(anaphylactic) type hypersensitivity to
penicillin
Second line
Clarithromycin 250 mg twice daily 7.5 mg/kg (maximum = 250 mg) twice 5 days† • For individuals with penicillin allergy
(oral) daily • Erythromycin-resistant isolates are
regarded as resistant to clarithromycin
and azithromycin as well
Azithromycin 500 mg once daily 12 mg/kg (maximum = 500 mg) once 3 days† • For individuals with penicillin allergy
(oral) daily • Erythromycin-resistant isolates are
regarded as resistant to clarithromycin
and azithromycin as well

* Primary care doctors should tailor antibiotic treatment to their clinical judgement. Definitive therapy should be based on microbiological
and antibiotic susceptibility results, if available
† For out-patients presenting with a sore throat and a modified Centor score of 4 or 5, a shor t course of oral antibiotic treatment is
recommended. However, for out-patients with positive laboratory results for group A Streptococcus or certain special reasons (eg,
clinical scarlet fever, household contact with scarlet fever, or known rheumatic hear t disease), a 10-day course of oral penicillin V,
amoxicillin, cephalexin or clarithromycin, or a 5-day course of oral azithromycin is recommended to achieve maximal eradication of
group A Streptococcus from the pharynx for primary prevention of acute rheumatic fever

lactam allergy or intolerance, positive throat culture amoxicillin or cephalexin, or a 5-day course of oral
results, and associated antibiotic susceptibility clarithromycin, or a 3-day course of oral azithromycin
profiles. is sufficient to treat out-patients presenting with a
A 10-day course of oral penicillin V, sore throat and a modified Centor score of 4 or 5. amoxicillin,
cephalexin or clarithromycin, or a However, for out-patients with positive laboratory
5-day course of oral azithromycin is recommended results for GAS or certain special reasons (eg,
by the Infectious Diseases Society of America, the clinical scarlet fever, household contact with scarlet
American College of Physicians, and the American fever, or known rheumatic heart disease), a 10-day
Academy of Pediatrics to achieve maximal course of oral penicillin V, amoxicillin, cephalexin
eradication of GAS from the pharynx for primary or clarithromycin, or a 5-day course of oral
prevention of acute rheumatic fever.6-8 However, a azithromycin is recommended to achieve maximal
recent systematic review comparing a 3- to 6-day eradication of GAS from the pharynx for primary
course of oral antibiotics (primarily cephalosporins) prevention of acute rheumatic fever (Table 2).
with a conventional 10-day course of oral penicillin
found similar effectiveness in children, but no
conclusions could be drawn on the complication Other issues
rates of acute rheumatic fever and poststreptococcal Alternative diagnosis should be considered for out-
glomerulonephritis.24 Furthermore, a 5-day course patients who present with unusually severe signs and
of antibiotic treatment is sufficient to mitigate the symptoms, such as difficulty swallowing, drooling,
clinical course of group C Streptococcus and group neck tenderness or swelling, or systemic unwellness.
G Streptococcus pharyngitis, as acute rheumatic They should be evaluated for potentially dangerous
fever is not a complication of infections due to these infections (eg, peritonsillar abscess, retro-/para-
organisms.8 pharyngeal abscess, acute epiglottitis and systemic
Based on the clinical experience that the infections). Out-patients who do not improve
prevalence of acute rheumatic fever is very low within 5 to 7 days or who have worsening symptoms
in Hong Kong nowadays, the Advisory Group should be evaluated for a previously unsuspected
agreed that a 5- to 7-day course of oral penicillin V, diagnosis (eg, infectious mononucleosis, primary

Hong Kong Med J Volume 25 Number 1 February 2019 www.hkmj.org 61

# The Advisory Group on Antibiotic Stewardship Programme in Primary Care #

HIV infection, or gonococcal

 pharyngitis). Infectious mononucleosis is a clinical
syndrome characterised by fever, severe pharyngitis
(which lasts longer than GAS pharyngitis), cervical or
diffuse lymphadenopathy, and prominent
constitutional symptoms. Out-patients who have
infectious mononucleosis and are treated with
amoxicillin may develop a generalised, erythematous,
maculopapular rash, and this should not be regarded
as a penicillin allergy. A properly taken sexual history
may hint at possibility of sexually transmitted
infections like HIV and gonorrhoea.
Management of out- patients with infections
should be individualised. Primary care doctors should
check, document, and inform out-patients well about
antibiotic treatment (eg, indications, side-effects,
allergies, contra-indications, potential drug-drug
interactions). Out-patients should take antibiotics
exactly as prescribed by their doctors. If their
symptoms change, persist, or get worse, they should
seek medical advice promptly.
Primary care doctors are invited to show their
commitment on judicious use of antibiotics by visiting
the “I Pledge” website (https://www.
chp.gov.hk/en/static/100755.html) and signing a
certificate on pledging to use antibiotics responsibly.
Furthermore, this invitation is open to general public.
Primary care doctors can engage their out-patients on
“I Pledge” during clinical encounters to facilitate
shared decision making on antibiotic prescribing.
Conclusion
Acute pharyngitis is one of the most common
conditions among out-patients in primary care in
Hong Kong. Practical recommendations on the
diagnosis and antibiotic treatment of acute
streptococcal pharyngitis are made in consultation
with key stakeholders in primary care settings such
that the recommendations can be tailored to their
needs. The recommendations are under regular
review, in consideration of the latest research, together
with local prevalence of pathogens and associated
antibiotics susceptibility profiles, and common local
Author contributions
practice.
The Advisory Group on Antibiotic Stewardship viewpoints of this study, literature review, and critical revision
Programme in Primary Care (2017-2018) for important intellectual content. ETK Lam was responsible for
1
 Angus MW Chan, MB, ChB (Glasg), FHKAM (Family literature search and drafting of the manuscript. All authors had
Medicine)
2 As editors of this journal, DVK Chao and MCS Wong were not
 Winnie WY Au, MB, BS
3 involved in the peer review process of this article. All other
 David VK Chao, FRCGP, FHKAM (Family Medicine)
4
 K Choi, MB, BS, FHKAM (Family Medicine)
5
 KW Choi, MB, ChB, FHKAM (Medicine)
6
 Sarah MY Choi, MB, ChB, FHKAM (Community
Medicine)
7
 Y Chow, MB, BS, FHKAM (Psychiatry)
8
 Cecilia YM Fan, MB, BS, FHKAM (Family Medicine)
9
 PL Ho, MD, FACP
62 Hong Kong Med J Volume 25 Number 1 February 2019
Funding/support
This research received no specific grant from any funding agency in the public,
10
 Eric MT Hui, FHKCFP, FHKAM (Family Medicine)
11
 KH Kwong, MB, BS, MFM (Clin) (Monash)
12
 Benjamin YS Kwong, BSc Pharm, MPharmS
13
 TP Lam, MD, FHKAM (Family Medicine)
14
 Edman TK Lam, MB, ChB, FHKAM (Pathology)
14
 KW Lau, BSc Pharm, MPharmS
14
 Leo Lui, MB, BS, FHKAM (Pathology)
14
 Ken HL Ng, MB, BS, FHKAM (Pathology)
15
 Martin CS Wong, MD, FHKAM (Family Medicine)
14
 TY Wong, MB, BS, FHKAM (Medicine)
16
 CF Yeung, MB, BS, FHKAM (Paediatrics)
17
 Joyce HS You, PharmD, BCPS (AQ Infectious Diseases)
18
 Raymond WH Yung, MB, BS, FHKAM (Pathology)
1 Hong Kong College of Family Physicians, Hong Kong
2 Infection Control Branch, Centre for Health Protection,
Department of Health, Hong Kong
3 Department of Family Medicine and Primary Health Care,
United Christian Hospital, Hospital Authority, Hong Kong 4 
Hong Kong Medical Association, Hong Kong
5 Hong Kong Society for Infectious Diseases, Hong Kong
6 Primary Care Office, Department of Health, Hong Kong
7 Quality HealthCare Medical Services Limited, Hong Kong
8 Professional Development and Quality Assurance, Department
of Health, Hong Kong
9 IMPACT Editorial Board, Reducing bacterial resistance with
IMPACT, 5th edition, Hong Kong
10 Department of Family Medicine, New Territories East
Cluster, Hospital Authority, Hong Kong
11 Human Health Holdings Limited, Hong Kong
12 Chief Pharmacist’s Office, Hospital Authority, Hong Kong
13 Department of Family Medicine and Primary Care, The
University of Hong Kong, Hong Kong
14 Infection Control Branch, Centre for Health Protection,
Department of Health, Hong Kong
15 Hong Kong Academy of Medicine, Hong Kong
16 Hong Kong Doctors Union, Hong Kong
17 School of Pharmacy, The Chinese University of Hong Kong,
Hong Kong
18 Hong Kong Sanatorium & Hospital, Hong Kong
All authors have made substantial contributions to the
full access to the data, contributed to the study, approved the
final version for publication, and take responsibility for its
accuracy and integrity.
Conflicts of interest
authors have no conflicts of interest to disclose.
Declaration
An earlier version of this article was published online in the
Centre for Health Protection website, November 2017
(https://www.chp.gov.hk/files/pdf/guidance_notes_acute_
pharynitis_full.pdf).
www.hkmj.org
commercial, or not-for-profit sectors.
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ABSTRAK

Pusat Perlindungan Kesehatan Departemen Kesehatan telah membentuk

kelompok penasihat tentang program pelayanan antibiotik dalam layanan primer
untuk merumuskan catatan pedoman dan strategi untuk mengoptimalkan penggunaan
antibiotik secara bijaksana dan meningkatkan program pelayanan antibiotik dalam
layanan primer. Faringitis akut adalah salah satu kondisi paling umum di antara
pasien rawat jalan di layanan primer di Hong Kong. Rekomendasi praktis untuk
diagnosis dan perawatan antibiotik faringitis streptokokus akut dibuat oleh kelompok
penasihat berdasarkan bukti klinis yang terbaik,prevalensi patogen lokal yang
tersedia, dan profil kerentanan antibiotik terkait, dan praktik lokal umum.

Pendahuluan Departemen Kesehatan mengadakan

Kelompok Penasihat pada Program
Pemerintah Daerah Administratif
Pengawasan Antibiotik dalam Perawatan
khusus Hong Kong sangat peduli
Primer (Kelompok Penasihat) yang
terhadap ancaman resistensi
terdiri dari para pemangku kepentingan
antimikroba. Di bawah otoritas Biro
utama di sektor publik dan swasta,
Makanan dan Kesehatan, dan dengan
akademisi, dan masyarakat profesional
upaya kolaboratif dari para pemangku
besar. Tujuannya adalah untuk
kepentingan, Strategi dan Rencana Aksi
merumuskan catatan pedoman dan
Hong Kong tentang Perlawanan
strategi untuk mengoptimalkan
Antimikroba (2017-2022) didirikan pada
penggunaan antibiotik secara bijaksana
Juli 2017. Rekomendasi di 6 bidang
dan meningkatkan Program Pengelolaan
utama dan 19 tujuan dimasukkan dalam
Antibiotik dalam Perawatan Primer.
hal ini. Rencana Aksi, bertujuan untuk
Catatan panduan tentang perawatan
memperlambat munculnya resistensi
antibiotik untuk infeksi umum yang
antimikroba dan mencegah
dilihat oleh dokter perawatan primer
penyebarannya.
telah dikembangkan berdasarkan pada

Sehubungan dengan Rencana Aksi bukti klinis terbaik yang tersedia,

ini, Pusat Perlindungan Kesehatan dari prevalensi patogen lokal dan profil
kerentanan antibiotik terkait, dan praktik simpleks, virus Epstein-Barr,
setempat. Bukti klinis terutama merujuk cytomegalovirus, dan human
pada praktik internasional, pedoman immunodeficiency virus (HIV).
terbaru dari organisasi internasional, dan Faringitis virus adalah suatu kondisi di
artikel tinjauan sistematis. Selain itu, mana antibiotik tidak diperlukan. Pasien
lembar informasi sederhana untuk rawat jalan dengan sakit tenggorokan
pasien rawat jalan dipersiapkan untuk dan gejala serta tanda yang terkait,
meningkatkan kesadaran dan termasuk konjungtivitis, coryza, batuk,
memungkinkan mereka untuk stomatitis ulseratif diskrit, suara serak,
menggunakan antibiotik dengan tepat. diare, dan eksantema virus,
Dokter perawatan primer memainkan kemungkinan besar memiliki penyakit
peran penting dalam tindakan mencegah virus, seperti flu biasa, influenza,
resistensi antimikroba dengan tidak herpangina, dan herpes oral. 
hanya mempraktikkan resep antibiotik
Streptokokus beta-hemolitik,
rasional tetapi juga mendidik dan
terutama grup A Streptokokus (GAS),
melibatkan pasien rawat jalan tentang
adalah patogen bakteri yang paling
penggunaan antibiotik yang aman
umum dari faringitis akut. Grup A
selama pertemuan klinis.
Streptococcus diperkirakan sekitar 10%
Faringitis akut adalah peradangan kasus faringitis akut pada orang dewasa
akut orofaring. Ini ditandai dengan sakit dan 15% hingga 30% pada anak-anak.
tenggorokan dan eritema faring. Ini Sebuah penelitian lokal di departemen
adalah salah satu kondisi yang paling kecelakaan dan gawat darurat di Hong
umum di antara pasien rawat jalan di Kong menunjukkan bahwa bagi mereka
perawatan primer di Hong Kong. yang mengalami sakit tenggorokan dan
tanpa gejala flu biasa atau influenza,
Faringitis akut biasanya penyakit
tingkat prevalensi faringitis GAS adalah
jinak dan sembuh sendiri dengan rata-
2,65% pada orang dewasa dan remaja
rata lama sakit 1 minggu. Ini sering
berusia > 14 tahun dan 38,6% pada
disebabkan oleh virus pernapasan
anak-anak berusia 3 hingga 14 tahun;
(misalnya, rhinovirus, coronavirus,
tidak satu pun dari anak-anak berusia <3
adenovirus, virus influenza, virus
tahun yang menderita faringitis GAS.
parainfluenza, virus syncytial
Kelompok A Streptococcus pharyngitis
pernapasan, dan metapneumovirus).
dapat menyebabkan supuratif (mis.
Virus lain yang menjadi perhatian
quinsy, otitis media, dan infeksi invasif
adalah enterovirus, virus herpes
lainnya) dan non-supuratif (mis. demam
rematik akut, glomerulonefritis Inggris pada tahun 2013. Kriteria Centor
poststreptococcal). Namun, demam dikembangkan dalam pengaturan
rematik akut belum digambarkan departemen darurat di Amerika Serikat
sebagai komplikasi dari kelompok C pada tahun 1981; kriteria Centor yang
Streptococcus atau kelompok G dimodifikasi menambah umur kriteria
Streptococcus pharyngitis. Faringitis Centor yang asli. Kriteria skor
streptokokus adalah bentuk faringitis FeverPAIN adalah Demam (selama 24
akut yang paling umum, di mana jam sebelumnya), Purulensi (nanah pada
pengobatan antibiotik diindikasikan. amandel), Hadir dengan cepat (dalam 3
hari setelah timbulnya gejala), amandel,
Diagnosis faringitis streptokokus akut
dan Tidak Ada batuk atau coryza;

Ada beberapa rekomendasi tentang masing-masing kriteria bernilai 1 poin

strategi diagnostik faringitis (skor maksimum 5). Skor 0 atau 1

streptokokus akut. Idealnya, untuk dikaitkan dengan kemungkinan 13%

mendapatkan diagnosis pasti, pasien hingga 18% untuk mengisolasi

rawat jalan dengan gejala dan tanda Streptococcus. Skor 2 atau 3 dikaitkan

yang menunjukkan penyebab bakteri dengan kemungkinan 34% hingga 40%

(misalnya, demam mendadak, untuk mengisolasi Streptococcus. Skor 4

limfadenopati serviks anterior, eksudat atau 5 dikaitkan dengan a 62% hingga

tonsilofaringeal) harus diuji untuk GAS 65% kemungkinan mengisolasi

dengan tes deteksi antigen cepat Streptococcus. Sebaliknya, kriteria

(RADT) dan / atau biakan tenggorokan. Centor yang dimodifikasi adalah usia 3

RADT negatif harus didukung oleh hingga 14 tahun, riwayat demam (lebih
biakan tenggorokan pada anak-anak dan dari 38 ° C), tidak adanya batuk, eksudat

remaja, tetapi tidak pada orang dewasa. atau pembengkakan pada amandel, dan

Secara praktis dan klinis, berbagai kelenjar getah bening serviks anterior

kriteria penilaian klinis telah serviks yang membengkak; masing-

dikembangkan untuk memperkirakan masing kriteria bernilai 1 poin (skor

kemungkinan faringitis streptokokus maksimum 5); perhatikan bahwa 0 poin

akut, dan kami menyarankan agar para diberikan untuk usia 15 hingga 44 tahun,

praktisi membuat keputusan klinis sedangkan -1 poin diberikan untuk usia

tentang pengujian laboratorium dan / ≥45 tahun. Skor -1, 0 atau 1 dikaitkan

atau pemberian antibiotik. Skor dengan kemungkinan 1% hingga 10%

FeverPAIN dikembangkan dalam untuk mengisolasi Streptococcus. Skor 2

perawatan primer sesuai pengaturan di atau 3 dikaitkan dengan kemungkinan

11% hingga 35% untuk mengisolasi yang harus dirawat untuk menyelesaikan
Streptococcus. Skor 4 atau 5 dikaitkan gejala satu per hari 3 adalah sekitar 3,7
dengan kemungkinan 51% hingga 53% untuk mereka yang memiliki swab
untuk mengisolasi Streptococcus. Saat tenggorokan positif untuk
ini ada ketidakpastian tentang alat Streptococcus; 6,5 untuk mereka yang
penilaian klinis mana yang lebih efektif. memiliki swab negatif, dan 14,4 untuk
mereka yang tidak menggunakan swab).
Berdasarkan pengalaman klinis
Pengobatan antibiotik dapat
bahwa RADT tidak tersedia secara
mempersingkat durasi sakit tenggorokan
umum, dan biakan tenggorokan
1 hingga 2 hari. Antibiotik dapat
memakan waktu, membutuhkan waktu
mencegah komplikasi infeksi GAS,
penyelesaian 2 hingga 3 hari, Kelompok
termasuk demam rematik akut atau
Penasihat sepakat bahwa menggunakan
komplikasi supuratif. Pasien rawat jalan
kriteria penilaian klinis lebih disukai
dianggap tidak menular lagi setelah 24
untuk tidak menggunakan tes
jam perawatan antibiotik. Namun,
laboratorium atau penilaian klinis apa
sedikit bukti yang mendukung
pun. Kriteria Centor yang dimodifikasi
pencegahan glomerulonefritis
lebih luas dan mudah digunakan (Tabel
poststreptococcal dengan pengobatan
1).
antibiotik. 

Pengobatan antibiotik faringitis

Meskipun demam berdarah terjadi
streptokokus akut
sepanjang tahun, telah ada pola

Meskipun gejala faringitis musiman di Hong Kong, dengan

streptokokus akut sembuh tanpa aktivitas yang lebih tinggi diamati dari

pengobatan antibiotik, ada pendapat Mei hingga Juni dan dari November

yang membenarkan pengobatan hingga Maret dalam beberapa tahun

antibiotik untuk menghilangkan gejala terakhir. Demam berdarah adalah infeksi

akut, pencegahan komplikasi supuratif bakteri yang disebabkan oleh GAS, dan

dan non-supuratif, dan pengurangan itu klasik hadir dengan demam, sakit

kemampuan menular. Sebuah tinjauan tenggorokan, lidah merah dan bengkak

sistematis terbaru tentang antibiotik (dikenal sebagai lidah stroberi), dan

untuk sakit tenggorokan menemukan ruam eritematosa dengan tekstur amplas.

bahwa manfaat klinisnya sederhana dan Ini terutama diagnosis klinis dan dapat

memerlukan pengobatan banyak dengan diobati dengan antibiotik yang tepat

antibiotik agar mendapat manfaat secara efektif.

(jumlah orang dengan sakit tenggorokan

 Setelah mempertimbangkan manfaat Kesehatan Perlindungan, yang
dan risiko (misalnya alergi dan efek melakukan isolasi bakteri dan pengujian
samping) dari pengobatan antibiotik, kerentanan antibiotik di depan umum
Kelompok Penasihat sepakat bahwa dan pengaturan rawat jalan pribadi di
pengobatan antibiotik diindikasikan Hong Kong, tingkat resistensi
untuk pasien rawat jalan yang eritromisin dari streptokokus beta-
mengalami sakit tenggorokan dan skor hemolitik (di mana GAS berkontribusi
Centor yang dimodifikasi 4 atau 5 dan pada sebagian besar dari mereka) dalam
untuk hasil pasien dengan hasil spesimen usap tenggorokan telah
laboratorium positif atau alasan khusus meningkat menjadi 59,1% dalam
tertentu (misalnya, demam scarlet klinis, beberapa tahun terakhir. Penelitian telah
kontak rumah tangga dengan demam menunjukkan bahwa eritromisin tingkat
scarlet, atau penyakit jantung rematik resistensi isolat GAS adalah 4% di
yang diketahui) [Tabel 2]. Amerika Serikat, 3,2% di Perancis,
32,8% di Spanyol, dan 65% di Taiwan.
Penisilin V oral atau amoksisilin
Fluoroquinolon (misalnya, levofloxacin
adalah antibiotik pilihan yang
oral) aktif terhadap GAS, tetapi mereka
direkomendasikan untuk pasien rawat
memiliki kebutuhan yang tidak penting
jalan yang tidak alergi terhadap agen ini.
dan tidak direkomendasikan untuk
Resistensi GAS terhadap penisilin dan
pengobatan rutin faringitis streptokokus
beta-laktam lainnya belum dilaporkan.
akut. Penggunaan fluoroquinolone yang
Sefalosporin generasi pertama
berlebihan dapat menyebabkan
(misalnya, sefaleksin oral) adalah agen
penundaan dalam diagnosis TB dan
lini pertama untuk pasien rawat jalan
peningkatan resistensi fluoroquinolon di
dengan alergi penisilin yang tidak alergi
antara Mycobacterium TBC di Hong
secara anafilaksis. Sefalosporin lain
Kong. Trimethoprim-sulfamethoxazole
(misalnya, cefaclor oral, cefuroxime)
tidak boleh digunakan karena tidak
adalah pilihan alternatif, tetapi mereka
menghilangkan GAS dari pasien rawat
tidak sebagai agen lini pertama karena
jalan dengan faringitis akut.
spektrum aktivitasnya yang luas.
Resistensi GAS terhadap makrolida Setelah mempertimbangkan prinsip
(mis., Azitromisin oral, klaritromisin, dasar bahwa antibiotik spektrum sempit
eritromisin) diketahui umum di Hong harus digunakan sebagai agen lini
Kong. Menurut data dari Divisi pertama untuk mengobati infeksi yang
Mikrobiologi Cabang Layanan tidak mengancam jiwa, Kelompok
Laboratorium Kesehatan Publik Pusat Penasihat setuju bahwa oral penicillin V,
amoxicillin atau cephalexin adalah agen komplikasi dari infeksi karena
lini pertama yang harus diobati. berdasarkan pengalaman klinis bahwa
faringitis streptokokus akut (Tabel 2). prevalensi demam rematik akut sangat
Pengobatan dengan makrolida oral atau rendah di Hong Kong saat ini,
fluoroquinolon pernapasan Kelompok Penasihat sepakat bahwa
membutuhkan pembenaran yang baik, pemberian oral penicillin V selama 5
termasuk riwayat alergi beta lactam atau sampai 7 hari amoxicillin atau
intoleransi laktam, hasil kultur cephalexin, atau 5 hari oral
tenggorokan positif l, dan kerentanan clarithromycin, atau 3 hari oral.
antibiotik terkait profil. Azitromisin cukup untuk mengobati
pasien rawat jalan yang mengalami sakit
10 hari penggunaan oral penicillin V,
tenggorokan dan skor Centor yang
amoxicillin, cephalexin atau
dimodifikasi 4 atau 5. Namun, untuk
clarithromycin, atau azithromycin oral 5
pasien rawat jalan dengan laboratorium
hari direkomendasikan oleh Masyarakat
hasil positif untuk GAS atau alasan
Penyakit Menular Amerika, American
khusus tertentu (misalnya, demam
College of Physicians, dan American
scarlet klinis, kontak rumah tangga
Academy of Pediatrics untuk mencapai
dengan scarlet). demam, atau penyakit
maksimal pemberantasan GAS dari
jantung rematik yang dikenal),
faring untuk primer pencegahan demam
pengobatan 10 hari penisilin oral V,
rematik akut. Namun, sebuah tinjauan
amoksisilin, sefaleksin atau
sistematis terbaru yang membandingkan
klaritromisin, atau oral selama 5 hari
3 - 6 hari antibiotik oral(terutama
azitromisin direkomendasikan untuk
sefalosporin) dengan 10 hari
mencapai maksimal dari pemberantasan
konvensional penisilin oral menemukan
GAS dari faring untuk pencegahan
efektivitas yang sama pada anak-anak,
primer demam rematik akut (Tabel 2).
tetapi tidak ada kesimpulan yang dapat
ditarik mengenai komplikasi dari Masalah lain
demam rematik akut
Diagnosis alternatif harus
danpoststreptococcal glomerulonefritis.
dipertimbangkan untuk pasien yang
Selanjutnya, waktu 5 hari dari
datang dengan tanda berat yang tidak
pengobatan antibiotik cukup untuk
biasa, seperti kesulitan menelan,
mengurangi klinis kelompok C
mengeluarkan air liur, nyeri atau
Streptococcus dan kelompok G
bengkak pada leher, atau
Streptococcus faringitis, sebagai demam
ketidaknyamanan sistemik. Mereka
rematik akut bukan merupakan
harus dievaluasi untuk berpotensi antibiotik persis seperti yang ditentukan
berbahaya infeksi yang lain(misalnya, oleh dokter mereka. Jika gejalanya
abses peritonsillar, abses retroparafaring, berubah, bertahan, atau memburuk,
epiglottitis akut dan infeksi sistemik). mereka harus segera berkonsultasi
Pasien rawat jalan yang tidak membaik dengan dokter.
dalam 5 hingga 7 hari atau yang
Dokter perawatan primer diundang
memiliki gejala memburuk harus
untuk menunjukkan komitmen mereka
dievaluasi untuk diagnosis sebelumnya
pada penggunaan antibiotik secara
yang tidak terduga (misalnya,
bijaksana dengan mengunjungi situs
mononukleosis primer menular, infeksi
web “I Pledge” (https: // www.
HIV, atau faringitis gonokokal).
Chp.gov.hk/en/static/100755.html) dan
Mononukleosis infeksiosa adalah
menandatangani perjanjian untuk
sindrom klinis yang ditandai oleh
menggunakan antibiotik secara
demam, faringitis berat (yang
bertanggung jawab. Selanjutnya,
berlangsung lebih lama dari faringitis
undangan ini terbuka untuk umum.
GAS),servikal atau difus limfadenopati,
Dokter perawatan primer dapat
dan gejala konstitusional yang
melibatkan pasien rawat jalan mereka
menonjol. Pasien rawat jalan yang
pada "I Pledge" selama pertemuan klinis
memiliki infeksius mononukleosis dan
untuk memfasilitasi pengambilan
diobati dengan amoksisilin dapat terjadi
keputusan bersama tentang resep
makulopapular yang umum, eritematosa
antibiotik.
ruam, dan ini tidak boleh dianggap
sebagai penisilin alergi. Riwayat seksual Kesimpulan
yang diambil dengan benar dapat
mengisyaratkan kemungkinan infeksi Faringitis akut adalah salah satu

menular seksual seperti HIV dan gonore. kondisi paling umum di antara pasien
rawat jalan perawatan primer di Hong
Manajemen pasien rawat jalan Kong. Rekomendasi praktis untuk
dengan infeksi harus diterapi secara diagnosis dan perawatan antibiotik akut
individual. Dokter perawatan primer faringitis streptokokus dibuat melalui
harus memeriksa, mendokumentasikan, konsultasi dengan para pemangku
dan memberi tahu pasien dengan baik kepentingan utama di rangkaian
tentang perawatan antibiotik (misalnya, perawatan primer sehingga rekomendasi
indikasi, efek samping, alergi, kontra tersebut dapat disesuaikan dengan
indikasi, potensi interaksi obat-obat). kebutuhan mereka. Rekomendasi
Pasien rawat jalan harus minum tersebut sedang secara berkala ditinjau,
dengan pertimbangan penelitian terbaru,
bersama dengan prevalensi patogen
lokal dan profil kerentanan antibiotik
terkait, dan praktik lokal yang umum.