Acute pharyngitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Your Organizational Guidance

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Acute KeelpijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2017Mal de gorge aiguPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2017

Analgesics and local anesthetics can be used for symptoms of sore throat, headache, and fever, although aspirin should be avoided in children because of its association with Reye syndrome. Salt water gargling is not proven to be efficacious, but it also does no harm.[50] Anesthetic sprays/lozenges may provide temporary relief from the pain of pharyngitis. One randomized, placebo-controlled trial demonstrated no benefit symptomatically from viscous lidocaine.[54] However, several other trials found a benefit from topical anesthetics, resulting in a decrease in symptoms and unnecessary antibiotic use.[55][56][57][58][59][60][61] In vitro evidence suggests that, in addition to analgesic properties, certain lozenges containing amylmetacresol and 2,4-dichlorobenzyl alcohol may have virucidal activity as well.[62]

Antibiotic treatment should be reserved for patients with microbiologically confirmed (with a positive rapid antigen test, nucleic acid amplification [via polymerase chain reaction] test, or culture) group A Streptococcus (GAS) pharyngitis and not based on a clinical diagnosis alone.[63] Antibiotic treatment is not recommended for patients with a negative rapid antigen test result.[25] Antibiotics may be prescribed to shorten the symptom duration, reduce transmission, and prevent complications such as rheumatic fever.[4] If pharyngitis symptoms have not improved after 3 or 4 days of antibiotic therapy, an alternate diagnosis should be considered.

Regarding the use of corticosteroids in the symptomatic treatment of acute pharyngitis, one Cochrane review reported an increased likelihood of complete resolution of pain at 24 hours by 2.40 times when they are given in combination with antibiotic therapy. However, the review cited lack of studies with adverse event reporting and lack of pediatric studies as a reason for caution in using corticosteroids, given the minimal clinical benefit.[64] [ ] Another systematic review found that patients who received single, low-dose corticosteroids were twice as likely to experience pain relief after 24 hours and 1.5 times more likely to have no pain at 48 hours.[65] In one double-blind, placebo-controlled randomized trial, in patients without indication for antibacterial therapy, a short course of oral corticosteroids did not increase symptom resolution at 24 hours but did have an association with increased symptom resolution at 48 hours. However, no effect was seen on healthcare attendance, days missed from work or education, or consumption of delayed antibiotic prescriptions.[66] The use of anti-inflammatory medications, including corticosteroids, in people with pharyngitis has been associated with increased incidence of peritonsillar abscess, sepsis, venous thromboembolism, and pathologic fracture.[67][68] Given the modest benefit and the significant potential for harm, the Infectious Diseases Society of America guidelines do not currently recommend corticosteroids for acute pharyngitis.[1][69]

Acute pharyngitis is the third leading cause of inappropriate antibiotic use.[70] In adults a delayed prescription approach limits antibiotic use.[71][72] [ ] [Evidence B] However, this may be inappropriate in children, where there is increased risk of rheumatic fever. Several initiatives to limit inappropriate antibiotic use have been shown to be effective in reducing inappropriate prescriptions without increasing physician re-consultation or reducing patient satisfaction.[73] However, one study found that 26% of pharyngitis cases given antibiotics did not have diagnostic evidence of bacterial infection.[74]

With group A Streptococcus (GAS) pharyngitis

The goal of treatment of GAS is to prevent acute rheumatic fever, reduce the severity and duration of symptoms, and prevent transmission.[1] Transmission of GAS results from contact with respiratory tract secretions of infected individuals. The rate of transmission for individuals infected with GAS to a close contact is approximately 35%.[75] The incubation period is 2-5 days.[4] During this time, the infection can be transmitted to others. However 80% of patients are noninfectious within 24 hours of starting antibiotics.[76] Antibiotic prophylaxis in individuals with a history of rheumatic fever is recommended to decrease the risk of recurrence of rheumatic fever and decrease the risk of rheumatic heart disease.[77] One Cochrane review concluded that antibiotics should be prescribed only after judging individual patients and only if the sore throat is likely to be of bacterial origin.[78]

There is no beta-lactam resistance in GAS, so treatment may be carried out with penicillin or amoxicillin, except in the case of a penicillin allergy where a macrolide, cephalosporin, or clindamycin may be used with caution.[1][4][25][79][80] [ ] GAS resistance to macrolides and clindamycin (inducible resistance) has been reported in children.[26][81][82] Doxycycline and trimethoprim/sulfamethoxazole are not recommended treatments.[1] Oral penicillin V (also known as phenoxymethylpenicillin) is the treatment of choice, given for 10 days' duration. For patients who are unable to complete a 10-day oral course, a single intramuscular dose of penicillin G benzathine can be given. Oral amoxicillin may be substituted in children, as its taste is more palatable than that of penicillin V.

Amoxicillin should be avoided when concomitant infectious mononucleosis is suspected, because of the increased possibility of developing a severe rash.[1] Recommended treatment course for oral beta-lactam antibiotics in children is 10 days.[26] Despite guideline recommendations, there is evidence that a shorter course (i.e., 3-6 days) of oral penicillin is as effective as a 10-day course in treating acute pharyngitis, without evidence of an increased risk of poststreptococcal glomerulonephritis or rheumatic fever.[83] One study found that a 3-day course of azithromycin or a 5-day course of cefaclor resulted in equivalent symptomatic and bacteriologic cure compared with a 10-day course of amoxicillin.[84] However, incidence rates of rheumatic fever or rheumatic heart disease were not assessed in this study.[84] Another study found penicillin V for 5 days was noninferior in clinical outcome to penicillin V for 10 days (at different doses) although, again, effect on the incidence rates of rheumatic fever or rheumatic heart disease were not assessed.[85] As the evidence is still emerging, shorter courses of antibiotics should still be considered an emerging alternative, rather than the recommended, primary option.[86][87]

With infectious mononucleosis

Rest remains a frequent recommendation, but its true usefulness is unknown. Avoidance of strenuous physical activity (including contact sports) in the initial 3-4 weeks of illness is desirable in light of the potential for splenic rupture, although cases have been demonstrated up to 8 weeks from initial diagnosis. Males have a higher rate of splenic rupture than females. An abdominal ultrasound is recommended to confirm resolution of splenomegaly prior to clearance for strenuous physical activity.[88]

Patients with severe systemic symptoms of infectious mononucleosis and its complications should be admitted to hospital.

Systemic corticosteroids should be reserved for patients with severe airway obstruction, severe thrombocytopenia, or hemolytic anemia.[89]

Intravenous immunoglobulin, which modulates the immune system response, may be used in patients with immune thrombocytopenia.

Evidence for the effectiveness or benefit of antiviral agents in patients with infectious mononucleosis remains limited.[90]

See Infectious mononucleosis.

With Candida infection

Candida albicans is usually susceptible to topical therapy. Mild to moderate cases of oral candidiasis may be treated with polyene antifungal agents (e.g., nystatin). It should be noted that nystatin suspension has a high sucrose content, and its frequent use, especially in a patient with xerostomia, may increase the risk of dental caries.

For people with fungal infection that is more widespread, involving more of the surfaces of the mouth, or in those with a longer duration of symptoms, an azole antifungal such as fluconazole is more appropriate.

See Oral candidiasis.

With diphtheria

Diphtheria antitoxin is the mainstay of therapy and should be administered promptly, as soon as there is a strong clinical suspicion of diphtheria. Laboratory confirmation of the diagnosis should not delay administration of antitoxin, as patients can deteriorate quickly. Antitoxin can only neutralize free toxin in the serum, and the efficacy decreases significantly after the onset of mucocutaneous symptoms, which signals the movement of toxin into the cells. Antibiotics are not a substitute for treatment with antitoxin, but serve to prevent further production of toxin by eradicating the Corynebacterium diphtheriae organism. They also treat localized cutaneous infections. In addition, antibiotics prevent transmission of the disease to contacts. C diphtheriae is usually susceptible to penicillin and erythromycin.[91]

See Diphtheria.

With tularemia

Antibiotic treatment with agents active against Francisella tularensis is the mainstay of therapy in all patients, regardless of the clinical manifestation. Standard isolation practices should be followed, and the clinical laboratory should be alerted to tularemia as a suspected diagnosis prior to clinical specimens being sent. The gold standard for therapy is an aminoglycoside. The Centers for Disease Control and Prevention (CDC) recommends gentamicin as the drug of choice based on experience and efficacy, particularly for severe cases.[92] The World Health Organization (WHO) recommends gentamicin as the drug of choice as it is more widely available, with streptomycin as an alternative if it is available.[93] The choice of agent ultimately depends on local guidance and availability of these drugs. Doxycycline is an alternative agent.[92]

See Tularemia.

With gonococcus or chlamydia

Gonococcus is harder to eradicate from the pharynx than from urogenital sites. For uncomplicated gonococcal infection of the pharynx, intramuscular ceftriaxone as a single dose is recommended. If chlamydia coinfection is identified, chlamydia should be treated with oral doxycycline, or azithromycin during pregnancy. A test of cure should be ordered to ensure eradication following treatment.[94]

See Gonorrhea infection (which also covers chlamydia coinfection).

Recurrent pharyngitis

Adult patients with recurrent pharyngitis may modestly benefit from tonsillectomy.[95][96][97] In children with recurrent episodes of GAS pharyngitis, tonsillectomy can be considered.[49]

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