Author:
Daniel B.Gingold
Brian J.Browne
Description
- Inflammation/infection of the pharynx
- Third most common complaint for physician visits
- 30 million cases diagnosed annually
- Group A β-hemolytic Streptococcus (GAS):
- Streptococcus pyogenes
- Unusual in children <3 yr old
- Cause of 20-30% of childhood pharyngitis
- Bimodal incidence, highest in ages 5-7 and 12-13 yr
- Cause of 5-15% of adult pharyngitis
- Peak months: January-May; also at the start of the school year
Etiology
- Viral (most common infectious cause [60-80%]):
- Rhinovirus (20%)
- Coronavirus (>5%)
- Adenovirus (5%)
- Herpes simplex virus (4%)
- Parainfluenza virus (2%)
- Influenza virus (2%)
- Coxsackievirus (<1%)
- Epstein-Barr virus (<1%)
- Acute human immunodeficiency virus (HIV)
- Bacterial:
- GAS (S. pyogenes [5-30%])
- Fusobacterium necrophorum (10%)
- Group C & G β-hemolytic Streptococcus (5%)
- Neisseria gonorrhea (<1%)
- Corynebacterium diphtheriae (<1%)
- Arcanobacterium haemolyticum (<1%)
- Chlamydia pneumoniae
- Mycoplasma pneumoniae (<1%)
- Syphilis
- Tuberculosis
- Fungal:
- Chemical burns
- Foreign bodies
- Inhalants
- Postnasal drip
- Malignancy
- GERD
Prehospital
- Observe/manage airway for respiratory distress
- Normal saline (NS) hydration for hypotension/dehydration
Initial Stabilization/Therapy
- ABCs
- Fluid resuscitation: 1 L (peds: 20 mL/kg) NS bolus for signs of volume depletion or if patient is unable to tolerate oral solutions
ED Treatment/Procedures
- Antipyretics/analgesics:
- Acetaminophen
- Ibuprofen
- Topical analgesics (e.g., Chloraseptic spray)
- GAS infection:
- Often mild and self-limited:
- Antibiotic therapy accelerates symptom relief (fever and pain) by 1-2 d
- Goal of antibiotic treatment is to reduce the incidence of acute rheumatic fever and suppurative complications and to resolve symptoms
- Penicillin V: Antibiotic of choice for GAS pharyngitis
- Cephalosporins or macrolides are acceptable alternative treatments for nonresponders and penicillin-allergic patients
- Corticosteroids:
- Single-dose steroids reduce pain and improve symptom resolution with or without concurrent antibiotic use, with no increase in complication rate
- Caution in diabetics and immunocompromised patients
- Potential complications of streptococcal infection:
- Suppurative complications:
- Peritonsillar abscess (quinsy)
- Retropharyngeal abscess
- Sinusitis
- Cellulitis/impetigo
- Otitis media/mastoiditis
- Nonsuppurative complications:
- Acute rheumatic fever:
- Rare in industrialized countries, but still the leading cause of cardiac death within first 5 decades of life
- Sequelae of GAS; not proven in association with group C or G
- Acute poststreptococcal glomerulonephritis
- Sydenham chorea
- Reactive arthritis
- Pand AS: Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection:
- Sudden onset of symptoms similar to obsessive-compulsive disorder
- Caused by an autoimmune reaction affecting the basal ganglia
- Uncommon and controversial
- Diphtheria:
- Goals of therapy:
- Prevent airway obstruction
- Treat infection
- Penicillin or macrolide antibiotic
- Complications:
- Exotoxin-mediated myocarditis and neuritis (cranial neuropathies)
- Gonococcal pharyngitis:
- Third-generation cephalosporin plus macrolide for possible Chlamydia coinfection
Medication
First Line
- Ibuprofen: 400-600 mg (peds: 10 mg/kg) PO q6-8h
- Acetaminophen: 650-975 mg (peds: 15 mg/kg) PO q 6-8h; not to exceed 4 g/24 hr
- Penicillin G:
- <27 kg: Benzathine penicillin G (Bicillin LA): 0.6 million units IM × 1
- >27 kg: Benzathine penicillin G (Bicillin LA): 1.2 million units IM × 1
- Penicillin V:
- <12 yr: 25-50 mg/kg/d PO div q6-8h × 10 d
- >12 yr: 250-500 mg PO q6-8h × 10 d
- Amoxicillin:
- 50 mg/kg PO per day, (max. 1 g) × 10 d
- Corticosteroids:
- Dexamethasone: 0.6 mg/kg IM/PO × 1 (max. 10 mg)
- Prednisone: 40-60 mg PO × 1
Second Line
- Macrolides:
- Azithromycin: 20 mg/kg/d × 3 d (max. 500 mg per dose)
- Erythromycin: 40-50 mg/kg PO div q6h × 10 d (max. 500 mg per dose)
- Oral cephalosporins:
- Cephalexin: 20 mg/kg/dose PO b.i.d × 5 d (max. 500 mg per dose)
- Special conditions:
- Suspected gonococcal pharyngitis:
- Ceftriaxone: 125-250 mg IM × 1
- Azithromycin: 1,000 mg PO × 1
Disposition
Admission Criteria
- Airway compromise
- Severe dehydration
- Suspected child abuse
Discharge Criteria
Able to tolerate oral intake
Follow-up Recommendations
- If symptoms do not improve within 72 hr
- Patients are no longer contagious after 24 hr of antibiotic treatment
- Mononucleosis patients should avoid contact sports
- AertgeertsB, AgoritsasT, SiemieniukRA, et al. Corticosteroids for sore throat: A clinical practice guideline . BMJ. 2017;358:j4090.
- HaywardGN, HayAD, MooreMV, et al. Effect of oral dexamethasone without immediate antibiotics vs placebo on acute sore throat in adults: A rand omized clinical trial . JAMA. 2017;317:1535-1543.
- SadeghiradB, SiemieniukRA, Brignardello-PetersenR, et al. Corticosteroids for treatment of sore throat: Systematic review and meta-analysis of rand omized trials . BMJ. 2017;358:j3887.
- ShapiroDJ, LindgrenCE, NeumanMI, et al. Viral features and testing for Streptococcal pharyngitis . Pediatrics. 2017;139:e20163403.
- ShulmanS, BisnoA, CleggH, et al. Clinical practice guideline for the diagnosis and management of Group A Streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America . Clin Infect Dis. 2012;55:e86-e102.
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