HEENT 08: Pharyngitis Flashcards
What are the causative organisms of viral pharyngitis?
- rhinovirus
- adenocirus
- coxsackievirus
- coronavirus
- respiratory synctial virus – parainfluenza
- epstein-barr virus
- orthomyxoviridae
What are the causative organisms of bacterial pharyngitis?
- Streptococcus pyogenes (GAS)
- Haemophilus influenzae
- Chlamydophila pneumoniae
- Mycoplasma pneumoniae
- Arcanobacterium hameolyticum
- Neisseria gonorrhoeae
- Treponema pallidum
What are the causative organisms of fungal pharyngitis?
- Candida albicans
Pharyngitis in Adults
viral in over 80% of adults
Bacterial Pharyngitis
GAS most common in kids and in winter/spring
What are the risk factors for pharyngitis?
- smoking or second-hand smoke
- allergic rhinitis
- winter to spring (November to May)
- exposure to infected person within last 2 weeks
What are the signs and symptoms of pharyngitis?
- acute sore throat (abrupt onset)
- fever
- tender cervical adenopathy
- erythematous pharynx and tonsils – possibly with pharyngeal exudate
- rash
- odynophagia
- palatal petechia
NOT cough, runny nose, conjunctivitis, diarrhea
What are the signs and symptoms of viral pharyngitis?
- pharyngeal redness, tonsilar erythema
- odynophagia, cough, rhinorrhea, conjunctivitis, hoarseness, diarrhea, rash
What are the signs and symptoms of bacterial pharyngitis?
- palatal petechiae, exudative tonsillar hypertrophy
- odynophagia, pahryngeal/tonsillar erythema +/- exudate, fever, palatal petechiae, tender cervical adenopathy, absence of cough, scarlet fever, history of exposure, winter to early spring presentation
How is the Modified Centor Score calculated?
- S: sans cough (absence): +1
- T: tender, swollen, anterior cervical lymph nodes: +1
- R: right age: 3-14 (+1), 15-44 (0), 45+ (-1)
- E: exudates (tonsillar), swelling: +1
- P: pyrexia (temperature > 38ºC): +1
When does the Modified Centor Score not work?
- during pandemics
- in groups at high risk for acute rheumatic fever – valvular heart disease, immunosuppressed
What does a Modified Centor Score ≥ 4 mean?
> 50% it is bacterial (GAS)
What does a Modified Centor Score ≥ 2 mean?
swab or RADT required
- throat swab and culture is gold standard for diagnosis – but waiting to do it ↓ time to treatment
- RADT has high specificity for GAS
What are the infectious complications of streptococcal pharyngitis?
- peritonsillar or retropharyngeal abscess
- cervical lymphadenitis
- sinusitis
- otitis media
- mastoiditis
What are the post-infection complications of streptococcal pharyngitis?
- glomerulonephritis
- acute rheumatic fever
What is acute rheumatic fever?
- inflammatory condition – immune response
- not contagious – GAS can be spread, but not ARF complication
- symptoms: fever, arthritis, HF, fatigue
- can lead to long-term heart damage – valvular disease
What are the red flags for diagnostic tests/further assessment?
- signs/symptoms of epiglottitis – sore throat and dysphagia, trouble swallowing, increased RR, changes in voice, stridor, drooling, unilateral neck swelling
- difficulty breathing
- chronic or recurrent sore throat
- symptoms worsen or do not resolve in 4-5 days
What is the appropriate management for viral pharyngitis?
pain management:
- NSAIDS, acetaminophen
- local pain: benzocaine (Cepacol, Chloraseptic), phenol (Chloraspetic) – available in lozenges and sprays, only work for 30-45 min
- no evidence for warm liquids, but may provide relief
Are corticosteroids recommended for viral pharyngitis?
NO
- dexamethasone 10mg PO once in adults
- dexamethasone 0.6mg/kg PO once in kids
What are the medications used to treat group A streptococcus (GAS)?
- penicillin
- amoxicillin
- cephalexin
- clindamycin
- clarithromycin
- azithromycin
What is the first-line treatment for group A streptococcus (GAS)?
penicillin V
- best evidence for preventing complications
- no documented GAS resistance
- BUT no suspension (kids)
What is the treatment for group A streptococcus (GAS) for patients with non-severe penicillin allergy?
cephalexin
What are the treatment options for group A streptococcus (GAS) for patients with severe penicillin allergy? (3)
- clindamycin – bad taste (kids)
- clarithroymycin – broad
- azithromycin – broad
What is the duration of therapy for group A streptococcus (GAS)?
10 days
- symptomatic improvement in around 4 days
Are antibiotics always required for group A streptococcus (GAS)?
no – often self-limiting
- BUT antibiotics reduce risk of complications – ARF is primary concern
What is described as treatment failure?
- worsening symptoms after 72 hours antimicrobial therapy
- early relapse 2-7 days post therapy
- late relapse or recurrent – confirm by culture
What is the treatment for GAS in adults after failure of first-line options?
- amoxicillin/clavulanate 875 mg PO BID x 10 days
- clindamycin 300 mg PO TID x 10 days
- azithromycin or clarithromycin
What is the treatment for GAS in children after failure of first-line options?
clindamycin, azithromycin or clarithromycin
What drugs are usually not recommended for GAS?
- fluoroquinolones – broad spectrum, higher risk of adverse effects, ciprofloxacin has no activity vs. streptococci
- trimethoprim/sulfamethoxazole – ineffective
- macrolides and clindamycin (only as alternatives) – significant resistance
What are asymptomatic GAS carriers?
- unlikely to transmit infection
- low risk for complications
- if high risk (immunocompromised), consider eradication therapy – 10 day course amoxicillin/clavulanate OR clindamycin
When do pharyngitis symptoms improve?
in 8-10 days – with OR without antibiotics
