Acute pharyngitis in

adolescents and adults

 Course content

Course roadmap
Basic concepts

Common infections

1
 “We need ways to target all
behaviours that contribute to the
Dr. Margaret Chan misuse of these fragile medicines.”
New York, USA
April 18, 2016

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 Core Competencies
Core competencies for
antimicrobial prescribing
C1: Understands the patient and the patient’s clinical needs
C2: Understands treatment options and how they support the
patient’s clinical needs
C3: Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
C4: Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
C5: Monitors and reviews the patient’s response to treatment

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 Objectives
• Understand the epidemiology of infectious etiologies of acute
pharyngitis
• Use clinical prediction scores and microbiologic tests to
identify those that may benefit from antimicrobial therapy.
• Recognize communication tools that can be used to educate
patients about their diagnoses and the appropriate use of
antimicrobials

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 Acute pharyngitis
• Common target for
antimicrobial stewardship
– Majority due viral
infections
– Broad-spectrum
antimicrobials used
inappropriately
Lord Akryl (http://cancer.gov) [Public domain], via Wikimedia Commons

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Harm associated with antimicrobials
• Adverse events
• Clostridium difficile
colitis
• Cost
• Emergence of
antimicrobial resistance

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 Case #1 Case #2

Sore throat Sore throat

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 Case 1
Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

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14 year-old male with:
2 day history of sore throat & fever

no rhinorrhea or cough

temperature 38.5o C

no acute distress
erythematous posterior pharynx with
exudate

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 Streptococcus pyogenes
• Group A Streptococcus
• Most common bacterial
etiology of pharyngitis
• More common in children
• Estimated to cause
5-15% of cases of sore
throat in adults
U.S. Centers for Disease Control and Prevention –
Medical Illustrator

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Acute pharyngitis

Viral pathogens are the

predominant cause of
pharyngitis overall!

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 Appropriate Inappropriate

Antibiotics for Antibiotics for

Group A Streptococcus Viral
pharyngitis pharyngitis

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 Modified Centor Score
Criteria Point Total Risk of group A
Temperature >38C 1 Score streptococcal
No cough 1 pharyngitis
Tender anterior cervical 1 ≥4 38 – 63%
adenopathy 3 27 – 28%
Tonsillar swelling or exudate 1 2 10 – 12%
Age 3 -14 years 1
Age 15 – 44 years 0 1 4 – 6%
Age > 44 years -1 0 2 – 3%

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 Diagnostic challenges
• Validated prediction
scores have limitations.
• May help determine who
does not need testing
• A positive microbiologic
test may represent
carriage

WHO/A. Kristensen

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 Assess for signs of viral
upper respiratory tract infection
• Conjunctivitis
• Coryza
• Cough
• Diarrhea
• Hoarseness
• Viral exanthema
• Oral ulcers
CDC/Brian Judd

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 Rapid antigen testing
A rapid antigen diagnostic
tests that is negative for
Group A Streptococcal
pharyngitis provides
reassurance that a
antibiotics are unlikely to be
needed.
WHO/A. Kristensen

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Remain vigilant:
• Life-threatening
causes of sore
throat
• Other treatable
causes (e.g.
gonococcal
pharyngitis)

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14 year-old male with:
2 day history of sore throat & fever

no rhinorrhea or cough

temperature 38o C

no acute distress
erythematous posterior pharynx with
exudate

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 Core Competencies 1 & 2

An informed choice

Drug Patient
Severity Source resistance factors Cultures

Optimal antibiotics

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 How severe is the patient’s condition?

Drug Patient
Severity Source resistance factors Cultures

Not severe

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 What is the likely source & pathogens?

Drug Patient
Severity Source resistance factors Cultures

• Group A Streptococcus pharyngitis?

• No signs of viral URI

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 What is the likely source & pathogens?
Criteria Point
Total Risk of group A
Temperature >38C 1
Score streptococcal
No cough 1
Tender anterior cervical Drug pharyngitis
Patient
Severity Source -
38 – 63% Cultures
resistance ≥ 4 factors
adenopathy
Tonsillar swelling or exudate 1 3 27 – 28%
Age 3 -14 years 1 2 10 – 12%
Age 15 – 44 years - 1 4 – 6%
Age > 44 years - 0 2 – 3%
TOTAL 4

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 How likely is resistance?

Drug Patient
Severity Source resistance factors Cultures

Unlikely. Group A streptococcus

remains sensitive to penicillin

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 Other considerations?

Drug Patient
Severity Source resistance factors Cultures

No allergies

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 Do I need cultures?

Drug Patient
Severity Source resistance factors Cultures

Rapid antigen
testing

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 Do I need cultures?

Drug Patient
Severity Source resistance factors Cultures

Rapid antigen
testing =
POSITIVE

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 Core Competencies 1 & 2

Drug Patient
Severity Source resistance factors Cultures

Penicillin

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55 year-old male with:
2 day history of sore throat & fever

+ rhinorrhea and mild cough

temperature 38.2o C

no acute distress
erythematous posterior pharynx with
exudate

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 How severe is the patient’s condition?

Drug Patient
Severity Source resistance factors Cultures

Not severe

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 What is the likely source & pathogens?

Drug Patient
Severity Source resistance factors Cultures

Viral upper respiratory tract

infection most likely

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 What is the likely source & pathogens?
Criteria Point
Total Risk of group A
Temperature >38C 1
Score streptococcal
No cough -
pharyngitis
Tender anterior cervical
Severity Source - Drug Patient
resistance 38 – 63% Cultures
≥ 4 factors
adenopathy
Tonsillar swelling or exudate 1 3 27 – 28%
Age 3 -14 years - 2 10 – 12%
Age 15 – 44 years - 1 4 – 6%
Age > 44 years -1 0 2 – 3%
TOTAL 1

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 Do I need cultures?

Guidelines recommend
against microbiologic
Drug Patient
Severity Source Cultures
testing in patients factors
resistance with
a low likelihood of
Group A Streptococcus
pharyngitis
No

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 Core Competencies 1 & 2

Drug Patient
Severity Source resistance factors Cultures

No antibiotics

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 Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

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 • Give specific diagnosis
Diagnostic
work-up
• Provide reassurance
• Clinical therapy
Symptomatic
Clinical Therapeutic • re-assessment
Advise Modify
against acquiring
assessment decisions antibiotics antimicrobials
Data by other means
• Offerreview
follow-up visit (safety
Patient
education net)

Initial evaluation Subsequent evaluation

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 Pharyngitis in adults

Group A streptococcal causes:

– 20 – 30% pharyngitis in
children
– 5 – 15 % of pharyngitis in
adults

By Lord Akryl (http://cancer.gov) [Public domain], via Wikimedia Commons

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 Patient expectations may drive
inappropriate antibiotic use
Important to educate
patients that the majority
of patients with sore
throat do well without
antibiotics.

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Clinicians may overestimate their
patients desire for antibiotics
Consider asking patients
directly if they expect to
receive antibiotics during
this encounter and why
to facilitate
communication.

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Review: Pharyngitis in Adults & Adolescents
Drug

prescription
Dose .............
.............
Route
.............

Duration

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Review: Pharyngitis in Adults & Adolescents
Drug

Acute pharyngitis in adults is

most commonly caused by a prescription
viral infection.
Dose .............
.............
Route
.............

Duration
Review: Pharyngitis in Adults & Adolescents
Drug
Clinical prediction scores can be
used to determine which patients
should undergo microbiologic prescription
testing for Group A Dose .............
.............
Route
.............
Streptococcal pharyngitis.

Duration
Review: Pharyngitis in Adults & Adolescents
Drug

Penicillin is first-line therapy in

non-allergic patients diagnosed prescription
with streptococcal pharyngitis. Dose .............
.............
Route
.............

Duration
Review: Pharyngitis in Adults & Adolescents
Drug

Directly ask regarding your

patient’s expectations for prescription
antibiotics to facilitate Dose .............
.............
Route
.............
communication.

Duration
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