Pharyngitis Flashcards
DL is a 10 year old female who, accompanied with her mother, presents to your pharmacy with a sore throat. You find out that her sore throat is pretty painful and makes swallowing difficult. You also note that her
anterior cervical lymph nodes are swollen and tender. Her symptoms started yesterday fairly suddenly and she also had a fever of 39.5°C, according to her mother.
What is your approach to this patient?
???
Pharyngitis
Causes?
- Infection of the pharynx
- Most common causes: viral (> 70% peds; 80-90% adult cases)
• Main bacterial cause: Group A β–hemolytic Streptococcus (S. pyogenes)
- Pharyngitis due to GABHS → AKA Strep throat
Location of Nasopharynx, Tongue, Oropharynx, Esophagus, Larynx, Trachea ?
see slide 5
Pharyngitis
Epidemiology
Group A beta-hemolytic streptococcal infections
• High risk groups:
- Children 5-15 years old
- Parents of school-age children
- Adults who work with children
- Rare for child < 3 years old to have pharyngitis caused by GABHS
- Incidence of GABHS greatest in winter/early spring
- Incubation period: 2-5 days
- Spread via direct contact (usually from hands) with droplets of saliva or nasal secretions
- Untreated, streptococcal pharyngitis patients are infectious during acute illness (usually 1-2 weeks) and another week afterwards
Pharyngitis
Symptoms
• Sore throat is most common symptom
• Other signs/symptoms may include:
fever, odynophagia, tender/enlarged cervical lymph
nodes, scarlatiniform rash
- Scarlet fever → characteristic rash with diffuse
erythematous eruption, usually in setting of
pharyngitis
* Rash appears within 24-48 hrs of symptom onset
* Texture described as having “sandpaper” feel
* Erythema begins on upper trunk/face, spreads
quickly to extremities
* Usually fades in 4-5 days
• Strongly indicative of viral etiology: rhinorrhea, cough,
hoarseness, conjunctivitis, diarrhea, oropharyngeal
vesicles
Pharyngitis
Complications
• Rare
• Include acute rheumatic fever, peritonsillar abscess,
retropharyngeal abscess, otitis media, rhinosinusitis,
reactive arthritis
• Acute rheumatic fever – autoimmune complication
- Characterized by inflammatory response affecting
heart, joints, brain, skin and soft tissue
- Carditis and arthritis are most common syndromes
- Highest incidence reported is in developing countries
- Occurs about 2-3 weeks after pharyngitis, typically in
setting of inadequate antibacterial therapy
Pharyngitis
Diagnosis
• Cannot diagnose with symptoms alone and cannot
diagnose with lab testing alone
- Only those with positive microbiologic testing for
GABHS require antibacterial treatment
- Positive test does not necessarily indicate disease –
patient may be a carrier and not actively infected
• Differentiation between symptoms suggestive of
GABHS from pharyngitis of other causes is important
Pharyngitis
Diagnosis
Modified Centor score
• Modified Centor score
- Helpful to identify patients who would benefit from
diagnostic testing for streptococcal pharyngitis
- 1 point for each of 4 criteria present
* Fever, tonsillar or pharyngeal exudate, tender
anterior cervical lymph nodes, absence of cough
- +1 point if < 15 years old; -1 point if > 45 years old
- 0-1 points – very low risk of strep
- 3-4 points – increased risk for strep
• Patients with symptoms strongly suggesting a viral
etiology (e.g. cough, rhinorrhea, hoarseness, etc.)
typically should not have testing for strep
Pharyngitis
Diagnosis
Throat swab
• Throat swab for culture
- Gold standard, but require 24-48 hrs for results
• Throat swab for rapid antigen detection test (RADT)
- More practical, results within minutes, less expensive,
point of care
• If RADT positive, does not require follow-up throat
culture
• If RADT negative, generally recommended to confirm
with throat culture for children/adolescents, but not
adults
** Throat is swabbed in the area of the tonsils (see slide
12 picture)
Pharyngitis
Antibacterial Therapy
Is it reasonable to delaying therapy while awaiting throat culture results? why?
Delaying therapy while awaiting throat culture results is reasonable because:
- Does not affect risk of complications
- GAS pharyngitis is often self-limiting disease (8-10
days)
- Delay in antibacterial therapy may ↓ reinfection rates
- Unnecessary antibacterial use can be avoided in up to
~ 50% of patients
Pharyngitis
Antibacterial Therapy helps reduce what?
Antibacterial therapy:
- ↓ severity of symptoms and duration of symptoms (by
~1 day)
- ↓ risk of transmission
- ↓ risk of suppurative complications and rheumatic
fever
Pharyngitis
Antibacterial Therapy:
Drug of choice?
Penicillin allergy (non-severe)?
Penicillin allergy (severe/anaphylactic)?
Drug of choice: Penicillin VK x 10 days
- Pediatrics: 40mg/kg/d po divided BID
- Adults: 600 mg po BID or 300 mg po TID
- No in vitro resistance
Penicillin allergy (non-severe): cephalexin x 10 days
- Pediatrics: 40 mg/kg/d po divided BID
- Adults: 500 mg po BID
Penicillin allergy (severe/anaphylactic)
- Pediatrics: Clindamycin 20mg/kg/d PO div TID (x 10d);
or azithromycin 20mg/kg PO daily (x 3 d); or
clarithromycin 15mg/kg/d PO div BID (x 10 d)
- Adults: Clindamycin 300 mg po TID (x 10 d); or
azithromycin 500 mg po daily (x 3 d); or
clarithromycin 250 mg po BID (x 10 d)
Pharyngitis
Symptomatic Relief
- Lozenges
- Acetaminophen
- Ibuprofen
- Hydration
Pharyngitis
Follow-up
• Follow-up cultures not routinely recommended, except if:
- History of rheumatic fever (↑ risk recurrence)
- Persistent symptoms
- Recurrent symptoms
• Symptoms may last 2-7 days
