AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Pharyngitis is a leading cause of pediatric ambulatory care visits. Examination of patients who present with sore throat may reveal tonsillitis, tonsillopharyngitis, or nasopharyngitis. The absence of pharyngeal inflammation or the presence of either rhinorrhea or laryngitis is much more likely to be associated with viral infection. However, no physical findings clearly separate group A beta-hemolytic streptococci (GABHS) from viral, other bacterial, or noninfectious causes.

The primary concern for pharyngitis in children aged 3-18 years is that untreated GABHS may subsequently cause rheumatic fever. To prevent this sequela, institute adequate antimicrobial therapy within 9 days of infection. Rapid antigen detection assays for GABHS are diagnostic if positive because the specificity of such tests is 98-99% (ie, 1-2% false-positive results); however, sensitivity is only 70% (ie, 30% false-negative results), requiring follow-up cultures for negative results.

The drug of choice to treat group A streptococci remains penicillin V, although many experts recommend a higher dosage than was used in the past. Other bacteria that occasionally cause pharyngitis and require antimicrobial therapy include gonococcus; Francisella tularensis; groups B, C, and G streptococci; Arcanobacterium hemolyticum; and Treponema pallidum. No treatment is of any benefit for the usual viral causes of pharyngitis. Discourage the use of throat lozenges, sprays, mouthwashes, decongestants, and antihistamines.

Pathophysiology

Multiple etiologies can cause irritation and inflammation of the pharynx. Causes in children range from viruses (eg, adenoviruses, enteroviruses, Epstein-Barr virus [EBV]), which often require only supportive therapy, to bacterial pathogens (eg, GABHS), which require antibiotic therapy. GABHS pharyngitis is spread via respiratory droplets through close contact.

No pathogen is isolated in nearly 30% of cases, and viruses are isolated in approximately 40% of cases. Other probable copathogens in children include Staphylococcus aureus, Haemophilus influenzae, Branhamella catarrhalis, Bacteroides fragilis, Bacteroides oralis, Bacteroides melaninogenicus, Fusobacterium species, and Peptostreptococcus species. Less common causes include Chlamydia trachomatis and Mycoplasma pneumoniae.

GABHS is the primary organism of concern in most pediatric cases of pharyngitis because appropriate antibiotic therapy is effective and can eliminate complications of rheumatic heart disease. For all cases, including viral etiologies, supportive care is necessary to prevent associated symptoms such as dehydration.

Frequency

United States

Approximately 10% of children seen by medical care providers each year have pharyngitis, and 25-50% of these children have GABHS. Approximately 20% of asymptomatic children are chronic carriers of GABHS.

International

The entire range of pharyngitis-causing pathogens is observed throughout the world. Certain pathogens that are virtually nonexistent in the United States cause pharyngitis in other areas. A good example is diphtheria, which has been nearly eradicated in the United States through immunizations. According to the Red Book, from 1990-1995, approximately 48,000 cases of epidemic diphtheria were reported in the former Soviet Union and central Asia.¹ Given the high case-fatality rate of 3-23% and the increased mobility of people, the potential for worldwide spread of diphtheria is a cause for concern. Consider rare or unsuspected causative agents in afflicted individuals who have traveled to high-risk areas or for individuals who have emigrated from these regions, especially in nonimmunized patients.

Race

Prevalence is equal among all races.

Age

Peak prevalence of GABHS pharyngitis is in children aged 5-10 years. In children younger than 2 years, most pharyngitis is of viral etiology, although GABHS is responsible in rare instances. Viral pharyngitis occurs in persons of all ages.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Clinical differentiation of the various pathogens of pharyngitis is difficult based on history or physical examination. In 1962, Feinstein et al noted, "The only typical feature of streptococcal infections is the failure to show a single, consistent, typical feature."
• History of exposure to known carriers, fever, headache, and abdominal pain in conjunction with sore throat suggest group A beta-hemolytic streptococci (GABHS) pharyngitis. Involvement of other mucous membranes (eg, conjunctivitis, coryza) suggests a viral etiology.
• Age may also dictate level of concern because GABHS is rarely a true pathogen in children younger than 2 years.
• Because supportive care is a primary goal in all cases, historical information regarding oral intake and hydration status is important.
• Obtain information about previous treatments, treatment failures, and medication allergies.

Physical

• While no single finding or combination of physical findings distinguishes GABHS from a viral etiology, the following items are suggestive:
• • GABHS pharyngitis is often associated with headache, pharyngeal exudate, painful cervical adenopathy, GI symptoms, chills, and high fever.
  • Viral pharyngitis is usually associated with sneezing, rhinorrhea, and cough.
  • Mononucleosis is typically exudative with extensive false membranes.
  • Herpangina (usually coxsackievirus A) is associated with papulovesicular lesions of the skin (ie, hand-foot-and-mouth disease).
  • Diphtheria, which is rare in developed countries, is associated with a thick gray membrane that is difficult to remove. It is highly friable and bleeds if manipulated.
• Any one particular sign or symptom, in addition to sore throat, has low specificity in distinguishing GABHS from viral etiologies. Also look for tonsillar asymmetry, which may be a sign of peritonsillar abscesses. This condition can occur in conjunction with soft palate bulging and deviation of the uvula.
• Pay particular attention to signs of dehydration because supportive care is a primary concern and essential regardless of the etiologic agent.

Causes

• Pharyngitis may be bacterial or viral in origin.
• Primary bacterial pathogens account for approximately 30% of cases in children.
• Viruses are isolated in approximately 40% of cases.
• In nearly 30% of cases, no pathogen is isolated.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Coxsackievirus infection

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

The following studies are necessary in individuals with suspected pharyngitis:

• Throat culture
• • A throat culture remains the criterion standard for diagnosis, although results can take as long as 48 hours.
  • Throat culture results are highly sensitive and specific for group A beta-hemolytic streptococci (GABHS), but results can vary based on technique, sampling, and culture media.
  • Most institutions and clinics have rapid testing, which is useful when immediate therapy is desired. Rapid testing can be highly reliable when used in conjunction with throat cultures. Several rapid diagnostic tests are available. Such tests are 70-90% sensitive and 95-100% specific compared with throat culture. Rapid screening followed by culture has become the standard in most institutions, especially in developed countries. The somewhat low sensitivity and specificity of clinical screening has led to this approach.
  • The Infectious Diseases Society of America (IDSA) has attempted to categorize some of the clinical differentiators. Although this guide can assist in clinical management, rapid screening followed by culture remains the best combination when resources are available. This clinical decision tool was tested in an emerging health care system and was found to be somewhat helpful in reducing unnecessary antibiotic use in resource-limited settings. Rates of disease outbreaks and availability of laboratory and clinical screening tools can help guide management. The IDSA categorization is as follows:
  • • Category 1 (probable viral pharyngitis) - Conjunctivitis, coryza, cough, diarrhea, viral-like exanthems
    • Category 2 (suggestive of possible bacterial pharyngitis) - Fever of more than 38.5°C, tender cervical nodes, headache, petechia of the palate, abdominal pains, or sudden onset (<12 h).
• Testing for viral etiologies
• • If Epstein-Barr virus (EBV) is considered, obtain a CBC count to detect atypical cells in the WBC differential and a Monospot test (or other rapid heterophile antibody test). EBV can also produce a subclinical hepatitis with a slightly elevated aspartate aminotransferase (SGOT)/alanine aminotransferase (SGPT).
  • Monospot findings are often negative in children younger than 6 years with EBV infections and in the first week of symptoms. In adolescents, Monospot testing detects approximately 90% of positive cases ultimately diagnosed with EBV-specific serologies.
  • Other viral etiologies usually do not require further diagnostic testing, but viral cultures can be obtained.

Imaging Studies

• Imaging studies are usually not necessary unless a retropharyngeal, parapharyngeal, or peritonsillar abscess is suspected. In such cases, a plain lateral neck film can be used as an initial screening tool.

Procedures

• For patients with peritonsillar abscess, needle aspiration and drainage is warranted. Retropharyngeal abscesses often require surgical drainage.
• For patients with signs of dehydration, administer adequate oral or intravenous fluids. Remember that pain may limit oral intake, complicating hydration maintenance in the patient.
• Parents often ask for referrals for tonsillectomy if their child has had multiple episodes of pharyngitis. Inform parents that tonsillectomy offers only temporary relief. A 50-80% reduction in GABHS pharyngitis is noted during the first 2 years following the procedure; however, by the third year after tonsillectomy, no difference is reported compared with control groups.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• For patients with viral pharyngitis, care should be supportive, with antipyretics for pain and fever. Ensure proper hydration. Intravenous hydration may be necessary.
• For patients with group A beta-hemolytic streptococci (GABHS), the antibiotic treatment of choice is penicillin. Assuming availability of rapid testing, physicians can decide, based on clinical severity, whether to immediately initiate therapy if a rapid test is positive for GABHS or to delay therapy until culture results are obtained. The issue of early versus delayed therapy has several considerations.²
• • Benefits of early treatment include the following:
  • • Therapy within 48 hours of symptom appearance appears to shorten duration of symptoms.
    • Early therapy limits spread to other children.
    • Early therapy allows the patient and family to return to their usual routine sooner. More than 80% of patients have culture-negative results after 24 hours of therapy; therefore, the child should remain out of school or daycare for 24 hours after starting therapy.
    • Early therapy limits losses to follow-up.
  • Disadvantages of early treatment include the following:
  • • Early therapy may lead to a higher failure rate secondary to an inability to create an immune response to the infection.
    • Rheumatic fever may be prevented if antibiotic therapy is initiated within 9 days of symptom onset.³
    • Possible drug reactions and expenses may be avoided by not immediately treating cases caused by pathogens other than GABHS (viruses in particular).
• Make decisions on an individual basis depending on available testing, severity of symptoms, availability to arrange follow-up care, and the need for patients and their families to quickly return to their regular routine.
• Some have also suggested that steroid use, dexamethasone (Decadron) in particular, may decrease the pain and symptom duration in those with both viral pharyngitis and streptococcal pharyngitis. This has been primarily shown in the adult population. In children, the length of symptoms has been shown to be minimally improved with adjunct steroid use; however, steroids might be considered in children with significant symptoms or discomfort.⁴

Surgical Care

• An ear, nose, and throat (ENT) specialist or a pediatrician experienced with needle drainage and aspiration can perform the procedure, if warranted by the existence of a peritonsillar abscess.

Consultations

• If the pediatrician is uncomfortable with drainage of a peritonsillar abscess, referral to an ENT specialist or emergency department (ED) physician is warranted.

Diet

• For most patients, no specific diet is needed, but adequate fluid intake and hydration are of vital importance. Monitor the patient to prevent secondary dehydration.

Activity

• To limit the spread to other individuals who have not been exposed, avoid school and new contacts during the initial 24 hours after beginning antibiotic therapy for GABHS.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Penicillin is the typical therapy for group A beta-hemolytic streptococci (GABHS) pharyngitis, in conjunction with prevention of dehydration and supportive care for pain. Improved compliance with regimens has been noted when penicillin treatment is administered 2-3 times daily, as compared with traditional regimens with 4 daily doses. Administer a minimum of 20 mg/kg/d; larger children are generally administered 500 mg divided into 2 daily doses for 10 days.

Several other medications, including some that are more palatable and meet with better compliance (eg, amoxicillin), have been approved to treat GABHS. Treat relapses or failure to improve with an antibiotic active against beta-lactamase–producing organisms (ie, macrolides, cephalosporins, amoxicillin/clavulanate). The hypothesis is that colonizing pharyngeal bacteria that produce penicillinase have inactivated penicillin, resulting in treatment failure.

Recently, corticosteroids (eg, oral dexamethasone) have been suggested as an adjunctive therapy to decrease pain and length of symptoms in adults with pharyngitis. One randomized controlled study in children found that the use of single-dose oral dexamethasone (0.6 mg/kg, not to exceed 10 mg) did not decrease the time to onset of clinically significant pain relief or the time to complete pain relief.⁴ However, for the subset of children with positive rapid streptococcal test results, improvement in the time to onset of pain relief was statistically significant (but marginally clinically significant).

Drug Category: Antibiotics

These agents are used to treat recurrent GABHS pharyngitis.

Drug Category: Corticosteroids

These agents may be used adjunctively to antibiotics to improve pain relief onset and are especially useful in patients with positive rapid streptococcal antigen test results.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Rarely, small children with pharyngitis who have signs and symptoms of dehydration after refusing to drink may require hospitalization for intravenous hydration. Usually, even patients who require intravenous hydration in the ED consume enough oral fluids following their intravenous fluid bolus to allow home management.

Further Outpatient Care

• Because more than 90% of children clear group A beta-hemolytic streptococci (GABHS) from their pharynx within 24 hours of antibiotic therapy initiation, they should remain out of school or daycare for 1 day.
• Reevaluate the patient if symptoms persist for more than 24-48 hours.
• Follow-up cultures are not routinely necessary unless concerns arise regarding recurrences or carrier states.
• Instruct families to encourage adequate hydration and to use antipyretics for pain and fever. Also instruct parents to seek immediate medical care or consult their primary medical provider if signs of dehydration occur or symptoms worsen.

In/Out Patient Meds

• In addition to adequate antibiotic therapy for patients with GABHS, administer antipyretics in all patients for pain and fever, irrespective of etiology. Ibuprofen (10 mg/kg/dose orally every 8 h) or acetaminophen (15 mg/kg/dose orally every 4-6 h) is effective.
• For patients with herpangina (stomatitis/pharyngitis), alumina/magnesia (Maalox) and diphenhydramine hydrochloride (Benadryl) mixed in a 1:1 ratio can be orally administered before meals to decrease associated discomfort and to help maintain good hydration. This medication can be dosed based on the Benadryl component (1.25 mg/kg/dose oral swish and swallow every 6 h as needed).

Complications

• Although the prevention of rheumatic fever is the primary reason for treating GABHS, several interesting facts were found during outbreaks of rheumatic fever in 1985 and 1990.
• No previous significant increases in GABHS were noted in the communities prior to the outbreaks. The outbreaks were observed in middle-class areas, where compliance rates with medical therapy are relatively high.
• Unlike most previous outbreaks, severe pharyngitis was rarely noted, and only 46% reported even having a recent sore throat. Only 24% of patients had sore throats serious enough to seek medical care. In addition, almost 20% of cases were in children who received antibiotics for pharyngitis (type of antibiotic, length of therapy, and compliance issues were not recorded).
• Therefore, outbreaks may, in fact, be most related to the "rheumatigenicity" of the GABHS.

Prognosis

• Prognosis is excellent for all types of pharyngitis. In rare cases, rheumatic fever can develop if GABHS is left untreated. Rarely, peritonsillar abscesses or other local complications develop. With supportive care to prevent dehydration and pain, pharyngitis, for the most part, is a self-limiting disease.

Patient Education

• For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education articles Sore Throat, Tonsillitis, and Strep Throat.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Potential for medical/legal pitfalls primarily involves missed diagnoses or failure to treat group A beta-hemolytic streptococci (GABHS). The complications are rare and usually occur during outbreaks of rheumatic heart disease; however, failure to diagnose and treat within the 9-day window from the start of symptoms can leave one open to potential litigation.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

1. American Academy of Pediatrics. Report of the committee on infectious diseases. Pickering LK, Baker CJ, McMillan J, Long S (Editors). Red Book. 27th Edition. Elk Grove Village, Il: American Academy of Pediatrics; 2006:430-439.
2. el-Daher NT, Hijazi SS, Rawashdeh NM, et al. Immediate vs. delayed treatment of group A beta-hemolytic streptococcal pharyngitis with penicillin V. Pediatr Infect Dis J. Feb 1991;10(2):126-30. [Medline].
3. Wannamaker LW, Rammelkamp CH Jr, Denny FW, et al. Prophylaxis of acute rheumatic fever by treatment of the preceding streptococcal infection with various amounts of depot penicillin. Am J Med. Jun 1951;10(6):673-95. [Medline].
4. Bulloch B, Kabani A, Tenenbein M. Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med. May 2003;41(5):601-8. [Medline].
5. Chi H, Chiu NC, Li WC, Huang FY. Etiology of acute pharyngitis in children: is antibiotic therapy needed?. J Microbiol Immunol Infect. Mar 2003;36(1):26-30. [Medline].
6. Denny FW, Wannamaker LW, Brink WR, et al. Landmark article May 13, 1950: Prevention of rheumatic fever. Treatment of the preceding streptococcic infection. JAMA. Jul 26 1985;254(4):534-7. [Medline].
7. Edress D. Dosing Handbook. 4^th ed. Egleston Scottish Rite Children's Healthcare System; 1999-2000.
8. Feder HM Jr, Gerber MA, Randolph MF, et al. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics. Jan 1999;103(1):47-51. [Medline]. [Full Text].
9. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. Jun 2005;52(3):729-47, vi. [Medline].
10. Gerber MA, Markowitz M. Management of streptococcal pharyngitis reconsidered. Pediatr Infect Dis. Sep-Oct 1985;4(5):518-26. [Medline].
11. Krober MS, Weir MR, Themelis NJ, van Hamont JE. Optimal dosing interval for penicillin treatment of streptococcal pharyngitis. Clin Pediatr (Phila). Nov 1990;29(11):646-8. [Medline].
12. Marvez-Valls EG, Stuckey A, Ernst AA. A randomized clinical trial of oral versus intramuscular delivery of steroidsin acute exudative pharyngitis. Acad Emerg Med. Jan 2002;9(1):9-14. [Medline].
13. Peter G, Smith AL. Group A streptococcal infections of the skin and pharynx (second of two parts). N Engl J Med. Aug 18 1977;297(7):365-70. [Medline].
14. Pichichero ME. Controversies in the treatment of streptococcal pharyngitis. Am Fam Physician. Dec 1990;42(6):1567-76. [Medline].
15. Roosevelt GE, Kulkarni MS, Shulman ST. Critical evaluation of a CLIA-waived streptococcal antigen detection test inthe emergency department. Ann Emerg Med. Apr 2001;37(4):377-81. [Medline].
16. Smeesters PR, Campos D, Van Melderen L, et al. Pharyngitis in low-resources settings: a pragmatic clinical approach to reduce unnecessary antibiotic use. Pediatrics. Dec 2006;118(6):e1607-11. [Medline].
17. Snellman LW, Stang HJ, Stang JM, et al. Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics. Jun 1993;91(6):1166-70. [Medline].
18. Van Cauwenberge PB, Vander Mijnsbrugge A. Pharyngitis: a survey of the microbiologic etiology. Pediatr Infect Dis J. Oct 1991;10(10 Suppl):S39-42. [Medline].

Article Last Updated: Nov 24, 2008