Treatment algorithm

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

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – supportive care

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ACUTE
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all patients
1st line – 

supportive care

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 may provide temporary relief from the pain of pharyngitis, although one randomized, placebo-controlled trial demonstrated no benefit symptomatically from viscous lidocaine.[54]

There are no current recommendations for the use of corticosteroids in the symptomatic treatment of acute pharyngitis.[1][69] One Cochrane systematic review reports that there is 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] [ Cochrane Clinical Answers logo ] ​ Infectious Diseases Society of America guidelines do not currently recommend this treatment.[1]

Primary options

acetaminophen: children: 10-15 mg/kg orally every 4-6 hours when required, maximum 75 mg/kg/day; adults: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

ibuprofen: children: >6 months of age: 10 mg/kg orally every 6-8 hours when required, maximum 40 mg/kg/day; adults: 200-400 mg orally every 4-6 hours when required, maximum 2400 mg/day

Secondary options

lidocaine oronasopharyngeal solution: (2%) children and adults: consult product literature for dose information

Plus – delayed or no antibiotic therapy

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ACUTE
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all patients
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without confirmed group A Streptococcus (GAS) or history of rheumatic fever
Plus – 

delayed or no antibiotic therapy

Treatment recommended for ALL patients in selected patient group

In instances when the rapid test for GAS proves negative, a reasonable approach is no antibiotics at all, with a next day follow-up if the throat culture is positive. A throat culture should be conducted in all patients with a negative rapid antigen test for GAS but who have symptoms consistent with GAS pharyngitis. 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]

Plus – antibiotic therapy

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ACUTE
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all patients
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with confirmed group A Streptococcus (GAS) or history of rheumatic fever
Plus – 

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

Antibiotic treatment should be reserved for patients with microbiologically confirmed (e.g., GAS) pharyngitis (a positive rapid antigen test, nucleic acid amplification [via polymerase chain reaction] test, or culture) and should not be 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 appropriate antibiotic therapy, alternate diagnoses should be considered.

The goal of treatment for GAS is to prevent acute rheumatic fever and rheumatic heart disease, reduce the severity and duration of symptoms, and prevent transmission.[1]

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] [ Cochrane Clinical Answers logo ] ​​​​​​​​ GAS resistance to macrolides and clindamycin (inducible resistance) has been reported in children.​[26][81][82]​​​​ Doxycycline and trimethoprim/sulfamethoxazole are not recommended for the treatment of GAS pharyngitis.[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. Avoid amoxicillin when treating GAS with concomitant infectious mononucleosis, because of the possibility of an amoxicillin 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]

Intense dosing strategies for penicillin V may speed recovery and may be a future strategy for the treatment of GAS positive pharyngotonsillitis.[98]​​

Antibiotic prophylaxis in individuals with a history of rheumatic fever is recommended to decrease the risk of recurrence of rheumatic fever.

Primary options

penicillin V potassium: children ≤27 kg: 250 mg orally two to three times daily for 10 days; children >27 kg and adults: 500 mg orally two to three times daily for 10 days

OR

penicillin G benzathine: children ≤27 kg: 600,000 units intramuscularly as a single dose; children >27 kg and adults: 1.2 million units intramuscularly as a single dose

OR

amoxicillin: children: 50 mg/kg/day orally given in 2 divided doses for 10 days, maximum 1000 mg/day; adults: 500 mg orally twice daily for 10 days

Secondary options

azithromycin: children: 12 mg/kg (maximum 500 mg/dose) orally once daily on day 1, followed by 6 mg/kg (maximum 250 mg/dose) once daily for 4 days; adults: 500 mg orally once daily on day 1, followed by 250 mg once daily for 4 days

OR

clarithromycin: children: 15 mg/kg/day orally given in divided doses every 12 hours for 10 days, maximum 500 mg/day; adults: 250 mg orally twice daily for 10 days

OR

erythromycin base: children: 25-50 mg/kg/day orally given in 4 divided doses for 10 days, maximum 2000 mg/day; adults: 250-500 mg orally four times daily for 10 days

OR

cephalexin: children: 25-50 mg/kg/day orally given in divided doses every 12 hours for 10 days, maximum 1000 mg/day; adults: 500 mg orally twice daily for 10 days

OR

cefadroxil: children: 30 mg/kg/day orally given in 1-2 divided doses for 10 days, maximum 1000 mg/day; adults: 1000 mg/day orally given in 1-2 divided doses for 10 days

OR

clindamycin: children: 20 mg/kg/day orally given in divided doses every 8 hours for 10 days, maximum 1800 mg/day; adults: 300-600 mg orally every 8 hours for 10 days

Consider – tonsillectomy

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ACUTE
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all patients
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with recurrent pharyngitis
Consider – 

tonsillectomy

Treatment recommended for SOME patients in selected patient group

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]

Plus – hydration, rest ± corticosteroid ± intravenous immune globulin

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ACUTE
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all patients
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with infectious mononucleosis
Plus – 

hydration, rest ± corticosteroid ± intravenous immune globulin

Treatment recommended for ALL patients in selected patient group

The goal of treatment is supportive care, including good hydration.

Rest remains a frequent recommendation, but its true usefulness is unknown. Avoidance of strenuous physical activity (including contact sports) in the initial 3 to 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. 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 immune globulin, which modulates the immune system response, may be used in patients with immune thrombocytopenia.

See Infectious mononucleosis.

Plus – antifungal therapy

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ACUTE
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all patients
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with Candida infection
Plus – 

antifungal therapy

Treatment recommended for ALL patients in selected patient group

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.

Plus – diphtheria antitoxin plus antibiotic therapy

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ACUTE
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all patients
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with diphtheria
Plus – 

diphtheria antitoxin plus antibiotic therapy

Treatment recommended for ALL patients in selected patient group

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.

Plus – antibiotic therapy

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ACUTE
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all patients
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with tularemia
Plus – 

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

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) recommend 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.

Plus – antibiotic therapy

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ACUTE
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all patients
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with gonococcus or chlamydia
Plus – 

antibiotic therapy

Treatment recommended for ALL patients in selected patient group

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).

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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