ACUTE

PHARYNGITIS

GROUP #9
 INTRODUCTION
 Acute pharyngitis is an inflammatory
syndrome of the pharynx and/or tonsils caused
by several different groups of microorganisms.

 Multiple structures in the mouth and pharynx

are susceptible to inflammation, which can
contribute to pain.
CONT…
 A primary cause of this inflammation can be
infection of the posterior oral pharynx lining.
Pharyngitis is often produced through the grouping
of 3 common signs and symptoms: fever,
inflammation of the pharynx, and sore throat.
Upper respiratory infections (URIs) occur
annually an average of 6 to 8 times for children
and 2 to 4 times for adults. Acute sore throat, or
pharyngitis, is a frequent presenting problem for
clinicians as part of a URI or other condition.
Upper respiratory infections (URIs) occur annually an average of
6 to 8 times for children and 2 to 4 times for adults. Acute sore
throat, or pharyngitis, is a frequent presenting problem for
clinicians as part of a URI or other condition

 In 1 year, about 40% of children and 15% of adults recounted an

episode of sickness with pharyngitis. These symptoms represent
the 11th most prevalent reason to seek outpatient health care, or
1% to 2% of all visits.

Nearly 10 million visits for children and more than 5 million visits
for adults are made to clinics, urgent care centers, and emergency
departments yearly for pharyngitis. The direct costs total nearly
$1.2 billion annually.
 PATHOPHYSIOLOGY
Invasion of mucosa.
Local inflammation.
Irritation of mucosa by secretion.
Release of local toxins, proteases.
 M protein fragment of GABHS and scarcolemma
antigen of myocardium.
Antigen antibodies of complex deposition in
glomeruli.
ETIOLOGY AND TRANSMISSION
 inflammation in the pharynx, nasopharynx,
and tonsillary area or the adjacent lymphoid
tissue.

caused by viruses that may transpire

because of the common cold and are often
self-limited.
ETIOLOGY AND TRANSMISSION
Adenovirus- 10% to 25% of cases.

Parainfluenza virus, enterovirus, rhinovirus,

respiratory syncytial virus (RSV), human
bocavirus, coronaviruses, and influenza A and
B.

Human herpes viruses- human

cytomegalovirus, Epstein-Barr virus, and
herpes simplex virus
ETIOLOGY AND TRANSMISSION
 Bacterial organisms- Groups C and G streptococci are naturally
occurring organisms in the oral cavity but may cause pharyngitis
 Less common microbials include the gram-negative
• Fusobacterium necrophorum,
• N gonorrhoeae,
• atypical Mycoplasma pneumoniae,
• Chlamydia pneumonia, fungal pathogens, and diphtheria.
The most well-known bacterial pathogen is Streptococcus
pyogenes, which causes GABHS.
 CLINICAL PRESENTATION
 Common identifiers- triad of
fever, sore throat, and
inflammation of the pharynx
with edema and erythema.
 Vesicles, ulcerations, or
exudates
Pharyngitis- a symptom.
 Pathogens may be discovered
in the oral cavity in
asymptomatic individuals.
 CLINICAL PRESENTATION
 Persists for 3 to 5 days.
 Oral cavity- check for the presence of swelling,
erythema, and exudates, in addition to symmetry.
Thorough examination of the neck- check for
masses, tender or sensitive lymph nodes, and
range of motion.
 CLINICAL PRESENTATION
If viral pathogens cause temporal symptoms, such as a
cough, conjunctivitis, rhinorrhea, coryza, hoarseness,
diarrhea, and/or a rash.

Findings of the pharyngeal examination of viral

pharyngitis- mild erythema to quite red and edematous.

Tonsillar hypertrophy may or may not be present.

Cobblestoning in the posterior pharynx- postnasal drip,

supporting a viral etiology.
 CLINICAL PRESENTATION
If GABHS is suspected as the cause of pharyngitis, the focal
point should be identification of any exposure to individuals with
known GABHS infection during the preceding 2 weeks.
GABHS patients generally have an abrupt onset of pharyngitis,
fever, dysphagia, erythema, and/or exudates in the pharynx and
anterior cervical lymphadenopathy.

 Throat discomfort may range from mild to severe, and throat

erythema may be minimal to beefy red. Other symptoms
associated with GABHS, such as headache, nausea, vomiting,
abdominal pain, and the characteristic scarlatiniform rash (which
feels like sandpaper), are not consistently present. However,
similar to that of viral pharyngitis, actual presentation may differ
 DIFFERENTIAL DIAGNOSIS
Because pharyngitis can be nonspecific, it is
essential to consider different causes. Both
infectious and noninfectious conditions should
be included in the differentials.

Cardiac disease and thyroid disease may

imitate pharyngitis. Influenza, diphtheria,
mononucleosis, gastroesophageal reflux
disease, URI, and allergic rhinitis should also
be considered.
 WORK-UP/LAB TESTS
In general testing for pharyngitis, the score is debatable, as it
may be skewed because of the colonization of the organisms in
asymptomatic patients. Respiratory virus detection can be
completed through rapid antigen direct tests (RADTs), direct
fluorescent antibody testing (DFA), and cultures. Often the
preferred method to collect these samples is through a nasal
wash or nasopharyngeal swab, both of which can be
uncomfortable for the patient and require skill from the clinician.

RADTs are simple to execute and produce results within 30

minutes for viral pharyngitis. However, results are restricted to
RSV and the influenza A and B viruses. DFA can be completed
within an hour for 8 known pharyngitis-causing viruses (RSV,
influenza A and B, adenovirus, human metapneumovirus, and
parainfluenza virus types 1, 2, and 3).
 WORK-UP/LAB TESTS
For GABHS, disease determination is usually
completed through RADT or throat culture. RADTs are
highly sensitive overall (90%) but depend on the
knowledge and skill of the person(s) attaining the swab
and performing the RADT. Treatment is indicated for a
positive RADT. Throat cultures are considered the gold
standard but have some disadvantages.

The most significant delay is the time frame of

receiving test results, which can be 18 to 24 hours. In
addition, a throat culture is not necessarily needed for
routine diagnosis of GABHS
 COMPLICATIONS
As viral pharyngitis is generally benign and self-limited, adverse
outcomes rarely exist. GABHS complications such as acute rheumatic
fever and acute glomerulonephritis are also uncommon, especially in
the developed world.

In addition to rheumatic fever and glomerulonephritis, possible

problems include acute otitis media, acute sinusitis, quinsy, cervical
lymphadenitis, mastoiditis, and peritonsillar abscess.

 Groups C and G streptococci also rarely cause complications, but

reactive arthritis and subdural empyema have been reported. Little
evidence supports adverse outcomes related to atypical pharyngeal-
causing organisms M pneumoniae or C pneumoniae and fungal
pathogens.
 GENERAL TREATMENT
 General treatment includes supportive care of antipyretics,
analgesics, and gargles. Benzocaine lozenges and throat
lozenges show some effectiveness.

 Acetaminophen (Tylenol) and nonsteroidal anti-inflammatory

drugs are effective in decreasing acute pharyngitis symptoms in
both children and adults.

Conflicting results are present related to the efficacy of zinc

gluconate, herbal treatments, and acupuncture. A short course of
corticosteroids may benefit some patients, especially those with
severe symptoms or who are unable to swallow.
 ANTIBIOTIC TREATMENT
The first-line antibiotic treatment for GABHS is penicillin to confirm
obliteration of the pathogen from the oral cavity. Penicillin may be
given orally for 10 days or as a single intramuscular shot. No antibiotic
resistance to penicillin has been documented for GABHS.
However, penicillin does have the potential for some adverse effects,
including anaphylaxis. Amoxicillin has comparable effectiveness to
penicillin and again should be prescribed orally for 10 days. Both
medications are also cheaper than alternatives.

For patients with an identified allergy that is neither nonanaphylactic

nor otherwise severe, an adequate alternate is cephalexin orally for 10
days. Those patients with a severe penicillin allergy may be prescribed
clindamycin, azithromycin, or erythromycin. Sulfonamides and
tetracyclines are not suggested because of high rates of antimicrobial
resistance and treatment failure
 JOURNAL

Antibiotic management of
acute pharyngitis in
primary care
The Advisory Group on Antibiotic Stewardship Programme in
Primary Care
 ABSTRACT
Acute pharyngitis is one of the most common
conditions among outpatients in primary care
in Hong Kong.
Practical recommendations on the diagnosis
and antibiotic treatment of acute streptococcal
pharyngitis are made by the Advisory Group
based on the best available clinical evidence,
local prevalence of pathogens and associated
antibiotic susceptibility profiles, and common
local practice.
 INTRODUCTION
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.
CONTD…
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.

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.
CONTD…
The Fever PAIN 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.
ANTIBIOTIC TREATMENT OF ACUTE
STREPTOCOCCAL PHARYNGITIS
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.

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.
CONTD..
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. 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.
CONTD…
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.

Excessive use of respiratory fluoroquinolones may lead to delay

in the diagnosis of tuberculosis and increased fluoroquinolone
resistance among Mycobacterium tuberculosis in Hong Kong.

 Trimethoprimsulfamethoxazole should not be used because it

does not eradicate GAS from out-patients with acute pharyngitis.
 OTHER ISSUES
Alternative diagnosis should be considered for outpatients who
present with unusually severe signs and symptoms, such as difficulty
swallowing, drooling, neck tenderness or swelling, or systemic
unwellness. They should be evaluated for potentially dangerous
infections (eg, peritonsillar abscess, retro-/parapharyngeal abscess,
acute epiglottitis and systemic infections).

Out-patients who do not improve within 5 to 7 days or who have

worsening symptoms should be evaluated for a previously
unsuspected diagnosis (eg, infectious mononucleosis, primaryHIV
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.
gonorrhoea.
CONTD..
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
 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 practice..