‘emedicine medscape.com Medscape Pharyngitis Updated: Apr 06, 2022 Author: John R Acerra, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, Ill, MD. Overview Practice Essentials Pharyngitis is defined as an infection or iritation of the pharynx or tonsils (see the image below). The etiology is usually Infectious, with most cases being of viral origin and most bacterial cases attributable to group A streptococc! (GAS). Other causes include allergy, trauma, toxins, and neoplasia. The group A beta-hemolytic streptococcal (GABHS) rapid antigen detection test is the preferred method for diagnosing GAS infection in the emergency department because of difficulties with culture follow-up.[1] Posterior pharynx with petechiae and exudates in a 12-year-old gir. Both the rapid antigen detection test and throat culture were positive for group A beta-hemolytic streptococci, Signs and symptoms Itis difficut to distinguish viral and bacterial causes of pharyngitis on the basis of history and physical examination alone, Nevertheless, the following factors may help rule out or diagnose GAS pharyngitis: ‘+ GAS infection is most common in children aged 4-7 years ‘+ Sudden onset is consistent with GAS pharyngi consistent with a viral etiology pharyngitis after several days of coughing or hinorrhea is more ‘+ Contact with others whe have GAS or cheumatic fever with symptoms consistent with GAS raises the likelihood of GAS. pharyngitis ‘+ Headache is consistent with GAS infection + Cough is not usually associated with GAS infection‘+ Vomiting is associated with GAS infection, though not exclusively so ‘+ Recent orogenital contact suggests possible gonococcal pharyngitis + Ahistory of rheumatic fever is important Centor criteria for GAS pharyngitis include the following: + Fever (1 point) + Anterior cervical lymphadenopathy (1 point) + Tonsillar exudate (1 point) + Absence of cough (1 point) Ascore of 0-1 makes GAS infection unlikely: a score of 4 makes it likely. In adults, the positive predictive value of these criteria is around 40% if 3 criteria are met and about 50% if 4 criteria are met. Physical examination includes the following: + Assessment of airway patency + Temperature + Hydration status ‘+ Head, ears, eyes, nose, and throat — Conjunctivitis, scleral icterus, rhinorrhea, tonsillopharyngeal/palatal petechiae, tonsillopharyngeal exudate, oropharyngeal vesicular lesions + Lymphadenopathy (cervical or generalized) + Cardiovascular evaluation + Pulmonary assessment + Abdominal examination + Skin examination ‘Soe Clinical Presentation for more detail Diagnosis Laboratory studies that may be helpful include the following + Group A beta-hemolytic streptococcal rapid antigen detection test (preferred diagnostic method in emergency settings) ‘+ Throat culture (criterion standard for diagnosis of GAS infection [90-99% sensitive}) ‘+ Mono spot (up to 95% sensitive in children; less than 60% sensitive in infants) + Peripheral smear + Gonococcal culture if indicated by the history Imaging studies generally are not indicated for uncomplicated viral or streptococcal pharyngitis. However, the following may be ‘considered! + Lateral neck flm in patients with suspected epiglottis or airway compromise + Softtissue neck CT if concen for abscess or deep-space infection exists throat swab may also be done. ‘See Workup for more detail. ManagementPrehospital care usually is not necessary for uncomplicated pharyngitis unless airway compromise is an issue. Intubation should not be attempted unless the patient stops breathing spontaneously. Emergency measures may include the following: + Assess and secure the airway, ifnecessary + Assess the patient fr signs of toxicity, epilotitis, or oropharyngeal abscess + Evaluate hydration status, and rehydrate as necessary + Assess for GAS infection if clinically suspected Most cases, whether viral or bacterial, are relatively benign and setflimited. Management of GAS infection, when indicated, includes the following: + Do not treat patients without a positive culture or positive rapid antigen detection test result ‘+ Perform a rapid antigen detection test if GAS is clinically suspected on the basis of the history and physical examination; if test results are positive, begin antibiotic therapy + Patiants with a low Centor score (0-1) can often be treated symptomatically for pharyngitis without further testing for GAS + Patients with a Centor score of 4 should have confirmation of GAS infection with an antigen test before being treated with antibiotics, unless such testing is unavailable ‘+ Household contacts of patients with GAS infection or scarlet fever should be treated for a full 10 days of antibiotics ‘without testing only if they have symptoms consistent with GAS; asymptomatic contacts should not be treated ‘+ Ifthe diagnosis is in doubt or the above criteria are not met, initiation of antibiotic therapy should await rapid antigen test or culture results ‘See Treatment and Medication for more detail Background Pharyngitis is defined as an infection or irritation of the pharynx and/or tonsils. The etiology is usually infectious, with most cases being of viral origin. These cases are benign and self-limiting for the most part. Bacterial causes of pharyngitis are also self- limiting, but are concerning because of suppurative and nonsuppurative complications. Other causes include allergy, trauma, toxins, and neoplasia [2] ‘The most significant bacterial agent causing pharyngitis in both adults and children is GAS infection (Streptococcus pyogenes); shown in the image below. ee { Streptococcus pyogenes at 100X magnification.Physical findings of GAS are shown in the image below. Posterior pharynx with petechiae and exudates in a 12-year-old gir. Both the rapid antigen detection test and throat culture were positive for group A beta-hemolytic streptococci, ‘Mycoplasma pneumoniae, Chlamydia pneumoniae, and Arcanobacterium haemolyticus are other bacterial causes of pharyngitis, but these pathogens are rare. Antibiotics covering atypical pathogens should not routinely be used to treat pharyngitis.[3] ‘The main ED concerns with pharyngitis are to rule out more serious conditions, such as epiglottitis or peritonsillar abscess, and to diagnose group A beta-hemolytic streptococcal (GABHS) infections. Airway obstruction is also of utmost importance for the ED physician treating pharyngitis, medicine Pathophysiology With infectious pharyngitis, bacteria or viruses may directly invade the pharyngeal mucosa, causing a local inflammatory response, Other viruses, such as rhinovirus and coronavirus, can cause iritation of pharyngeal mucosa secondary to nasal secretions [3] ‘Streptococcal infections are characterized by local invasion and release of extracellular toxins and proteases. In addition, M protein fragments of certain serotypes of GAS are similar to myocardial sarcolemma antigens and are linked to rheumatic fever and subsequent heart valve damage. The prevalence rates of these serotypes of GAS have been becoming rarer over the past several years. Acute glomerulonephrtis may result from antibody-antigen complex deposition in glomeruli. [4] medicine Frequency United States Children experience more than 5 upper respiratory infections (URIs) per year and an average of one streptococcal infection ‘every 4 years. The occurrence in adults is about one half that rate, The most significant bacterial agent causing pharyngitis in both adults and children is GAS infection (Streptococcus pyogenes), and the mast common viruses are rhinovirus and adenovirus. GAS is most prevalent in late fall through early spring {2} International ‘The incidence of pharyngitis is higher internationally. Antibiotic resistance may be more prevalent in some countries because of ‘overprescription of antibiotics. Note, however, that despite this, there has never been a documented case of GAS resistant to penicilin anywhere in the world {5}A study by Banigo et al reported that the reduction in the number of tonsillectomies performed in England (28,309 in 1990/1991 vs 6327 in 2013/2014) correlates with an increase in the number of hospital admissions in that country for acute tonsilitis and pharyngitis and with an increase in invasive group A beta-hemolytic streptococcal (GABHS) infections. Indeed, over the course of the 1990/1991 to 2013/2014 period, the number of invasive GABHS infections rose more than two-fold in children aged 14 years or younger.(6] medicine Mortality/Morbidity In the developing world, an estimated 20 milion people are affected by acute rheumatic fever and rheumatic heart disease, making this the leading cause of cardiac death during the fist 5 decades of lf. This incidence of rheumatic heart disease is ramatically lower in most developed countries, but localized outbreaks have occurred in the Western world. Despite this, new cases of rheumatic heart disease in the United States are extremely rare.[7} The US Centers for Disease Control and Prevention {CDC) stopped tracking the incidence of rheumatic heart disease inthe United States in 1994, when the incidence dropped to less than 1 case per milion US general population [6] Other sequelae of streptococcal pharyngitis include acute glomerulonephrits, peritonsilar abscess, and toxic shock syndrome Mortality from pharyngitis is rare but may result rom one of its complications, most notably airway obstruction. Age Pharyngitis occurs with much greater frequency in the pediatric population. Approximately 15-30% of sore throats in children are: ‘caused by group A beta-hemolytic streptococcal (GABHS) infections, compared with 5-15% of adults.[2, 9] ‘The peak incidence of bacterial and viral pharyngitis occurs in the school-aged child aged 4-7 years, with GABHS occurring primarily in patients aged 5-15 years. Pharyngltis, especially GAS infection, is rare in children younger than 3 years. Ina study of 3098 pediatric patients with pharyngitis, Nishiyama et al found the prevalence of GAS pharyngitis to be 1.2% in patients below age 1 year and 3.9% in patients aged 1 year-(10] medicine Presentation History Viral and bacterial causes of pharyngitis are similar, and the differentiation of the etiology is difficult based on history and physical examination alone. Signs and symptoms alone cannot be used to rule out or diagnose GAS pharyngitis [11] Despite this, classic presentations are described below. ‘+ GAS infection is most common in children aged 4-7 years. ‘+ Sudden onset is consistent with a GAS pharyngitis. Pharyngitis following several days of coughing or thinorthea is more Consistent with a viral etiology. ‘+ Person has been in contact with others diagnosed with GAS or rheumatic fever presenting with symptoms consistent with GAS are more likely to have GAS pharyngitis. + Headache is consistent with GAS infection, + Cough is not usually associated with GAS infection + Vomiting is associated with GAS infection but may be present in other types of pharynatis + Anistory of recent orogenital contact suggests the possibilty of gonococcal pharynaits. + Ahistory of rheumatic fever is important when considering treatment. ‘The Centor criteria have been used in the past as a way to diagnose and treat GAS pharyngitis (12] These include the following + Fever ‘+ Anterior cervical lymphadenopathy+ Tonsillar exudate + Absence of cough (One points awarded for each ofthe criteria met, wth patients scoring 0-1 unlikely to have GAS infection and patints with a score of 4 more likely to have GAS. Acinical diagnosis of GAS infection using these criteria can result in an overestimation of the incidence of streptococcal pharyngitis, as many bacterial and viral cases of pharyngitis can be indistinguishable on clinical grounds. This can lead to an overtreatment of pharyngitis with antibiotics (13) In aduts, the positive predictive value ofthe Contor entera for predicting GAS pharyngitis is around 40% i3 itera are met, and about 50% i enter are met [14] These criteria along with other clinical features should be used to guide treatment for pharyngitis in adults. A modified version of the Cantor score, in which age is also taken account (and which is also called the Mclsaac score), can be used in diagnosis as well 115, 16) Cmedicine Physical ‘See the list below: + Airway patency must be assessed and addressed first, ‘+ Temperature: Fever is usually absent or low-grade in viral pharyngitis, but fever is not reliable to differentiate viral or bacterial etiologies. ‘+ Hydration status: Oral intake usually is compromised because of odynophagia; therefore, various degrees of dehydration result. ‘+ Head, ears, eyes, nose, and throat (HEENT) © Conjunctivitis may be seen in association with adenovirus, © Sdleral icterus may be seen with infectious mononucleosis © Rhinorrhea usually is associated with a viral cause. © Tonsillopharyngeal/palatal petechiae are seen in GAS infections and infectious mononucleosis. © Atonsilopharyngeal exudate may be seen in streptococcal infectious mononucleosis and occasionally in M pneumoniae, C pneumoniae, A haemolyticus, adenovirus, and herpesvirus infections. Therefore, exudate does not differentiate viral and bacterial causes. ‘© Oropharyngeal vesicular lesions are seen in coxsackievirus and herpesvirus. Concomitant vesicles on the hands and feet are associated with coxsackievirus (hand-foot-and-mouth disease). ‘+ Lymphadenopathy: Tender anterior cervical nodes are consistent with streptococcal infection, whereas generalized adenopathy is consistent with infectious mononucleosis or the acute lymphoglandular syndrome of HIV infection. ‘+ Cardiovascular: Murmurs should be documented in an acute episode of pharyngitis to monitor for potential rheumatic fover. ‘+ Pulmonary: Pharyngitis and lower respiratory tract infections are more consistent with M pneumoniae or C pneumoniae, particularly when a persistent nonproductive cough is present, + Abdomen: Hepatosplenomegaly can be found in infectious mononucleosis infection. + Skin © Asandpapery scarlatiniform rash is seen in GAS infection (see Scarlet Fever) [17] ‘© Maculopapular rashes are seen with various viral infections and with infectious mononucleosis empirically treated with penicillin Astudy by Jo et al indicated that in the diagnosis of GAS pharyngitis, the following five signs are significantly associated with the disease, as determined through multivariate logistic regression analysis: pharyngeal hemorrhage (adjusted odds ratio [aOR] = 3.90), palatal hemorthage (aOR = 2.18), rash (aOR = 2.08), tonsilar swelling (aOR = 1.69), and enlarged cervical nodes (aOR = 1.58).[18]Causes ‘See the list below: ‘+ Bacterial pharyngitis © Group A beta-hemolytic streptococci (GABHS): The classic clinical picture includes a fever, temperature of greater than 101.5°F; tonsillopharyngeal erythema and exudate; swollen, tender anterior cervical adenopathy; headache; ‘emesis in children; palatal petechiae; midwinter to early spring season; and absent cough or rhinorrhea {17, 19] ‘© Group C, G, and F streptococci may be indistinguishable clinically from GAS infection. Acute glomerulonaphrits is an extremely unusual complication of group C streptococcal pharyngitis, but a relationship between group G streptococcal pharyngitis and acute glomerulonephritis has not be established. Acute rheumatic fever has not been described as a complication of either. They may be associated with food-bome outbreaks. The benefit of antibiotic therapy with these types of streptococc' is unproven at this time.[7] © Arcanabacterium (Corynebacterium) haemolyticus is more common in young adults and is very similar to GAS infection, including a similar scarlatiniform rash. Patients often have a cough. Occasional outbreaks have been reported, ‘© M pneumoniae in young adults presents with headache, pharyngitis, and lower respiratory symptoms. Approximately 75% of patients have a cough, which is distinctive from GAS infection. ‘© C pneumoniae has a alinical picture similar to that of M pneumoniae. Pharyngitis usually precedes the pulmonary infection by about 1-3 weeks. © Neisseria gonorrhoeae is a rare cause of pharyngitis. A careful history is important since infection usually follows ‘orogenital contact. It may be associated with severe systemic infection, ‘© Corynebacterium diphtheriae is rare in the United States. A foul-smelling gray-white pharyngeal membrane may result in airway obstruction. + Viral pharyngitis(4] © Adenovirus: The distinguishing feature of an adenovirus infection is conjunctivitis associated with pharyngitis (pharyngoconjunctival fever). Its the most common etiology in children younger than years, ‘© Herpes simplex: Vesicular lesions (herpangina), especially in young children, are the hallmark. In older patients, pharyngitis may be indistinguishable from GABHS infection © Coxsackieviruses A and B: These infections present similarly to herpes simplex, and vesicles may be present. If vesicles are whitish and nodular, itis known as lymphonodular pharyngitis. Coxsackievirus A16 may cause hand- foot-and-mouth disease, which presents with 4- to 8-mm oropharyngeal ulcers and vesicles on the hands and feet, and, occasionally, on the buttocks. The oropharyngeal ulcers and vesicles resolve within 1 week. © Epstein-Barr virus (EBV): Clinically known as infectious mononucleosis, itis extremely difficult to distinguish from GAS infection. Exudative pharyngitis is prominent. Distinctive features include retrocervical or generalized adenopathy and hepatosplenomegaly. Atypical lymphocytes can be seen on peripheral blood smear. Viral cultures from washings are about 20% sensitive in adults, ‘© CMV: Presentation of CMV is similar to the presentation of infectious mononucleosis. Patients tend to be older, are sexually active, and have higher fever and more malaise, Pharyngitis may not be a prominent complaint. © HIV-1; This is associated with pharyngeal edema and erythema, common aphthous ulcers, and a rarity of ‘exudates. Fever, myalgia, and lymphadenopathy also are found. + Other causes of pharyngitis: © Oral thrush is due to candidal species, usually in patients who are immunocompromised. It may be common in young children and presents with whitish plaques in the oropharynx. © Other causes include dry air, allergy/postnasal drip, chemical injury, gastroesophageal reflux disease (GERD), ‘smoking, neoplasia, and endotracheal intubation. © Arare but life-threatening cause of pharyngitis in young adults is Lemierre's syndrome. This condition is usually ‘caused by the anaerobic bacterium, Fusobacterium necrophorum, and is characterized by a oropharyngealInfection with evidence of septic thrombophlebitis. The incidence is approximately one in a milion, but it should be ‘considered when a critically il patient presents with pharyngitis. [20] @medicine DDx Diagnostic Considerations Thi include the followingl21] + Allergic rhinitis with postnasal drip + Airway obstruction + Head and neck neoplasias ‘+ Gastroesophageal reflux disease (GERD) + Peritonsiliar cellulitis ferent I Diagnoses + Candidiasis in Emergency Mecicine + Diphtheria » Emergent Management of Croup (Laryngotracheobronchitis) «Emergent Manayemant of Gononinea + Emergent Management of Pediatric Epiglotiis + Epiglottis + Hand-Foot-and-Mouth Disease in Emergency Meticine + Herpes Simplex Vitus (HSV) in Emergency Medicine '* Infectious Mononucleosis (IM) in Emergency Medicine + Pediatic Pharyngitis + Paritonsilar Abscess in Emergency Moticine + Phannats + Pneumonia, Mycoplasma + Retropharyngeal Abscess + Rheumatic Fever in Emergency Medicine + Scarlet Fever medicine Workup Workup Laboratory StudiesGABHS rapid antigen detection test This is the preferred method for diagnosing GAS infection in the emergency department because of difficulties with culture follow-up. (See the image below.) CAC Ole Soec 08 HEL f Bee wecuuresuab™ Rapid antigen detection test for group A beta-hemolytic streptococci Only patients with a high clinical ikethood of GAS pharyngitis should be tested, Patients with a Centor score of 0-1 should be treated symptomatically without testing [22] (On the other hand, in a multicenter, prospective, cross-sectional study, Cohen etal suggested that all children with pharyngitis undergo the rapid antigen detection test for GAS, stating that assessment of signs and symptoms is an ineficient means of determining in which patients the test should be used [23] ) ‘Antigens are specific, but sensitivities vary. The sensitivity of the GABHS rapid antigen detection test is 70-90%, and the speaifcity is 80-100%, depending on the manufacturer.[24, 25, 26, 27] Children with a negative antigen test should have a follow-up culture unless the antigen being used in the office has been shown to be as sensitive as a culture.{17] ‘The use of a GABHS rapid antigen detection test can decrease the use of unnecessary antibiotics in pediatric patients when used properly [28] ‘Adults do not need follow-up culture after a negative antigen test because of the low incidence of GAS in this population (13) Throat culture This is the criterion standard for diagnosis of GAS infection (90-89% sensitive).[29] Although less expensive than the rapid antigen detection test, itis not be the best test to use in the emergency department because of difficulty with follow-up. The guidelines that recommend cultures for GAS screening are aimed at office-based practices and not the emergency department. Patients can be treated up to 9 days after onset of symptoms to prevent acute rheumatic fever, so immediate antibiotic therapy is not crucial if patients can be easily contacted for follow-up should a culture become positive [2] Other Additional tests include the following: + Mono spot is up to 95% sensitive in children (less than 60% sensitivity n infants) + Peripheral smear may show atypical lymphocytes in infectious mononucleosis '*! + Perform gonococeal culture as indicated by history + Acomplete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein have a low predictive value and usually are not indicated (°°) Cmedicine Imaging Studies ‘See the list below:‘+ Imaging studies generally are not indicated for uncomplicated viral or streptococcal pharyngitis ‘+ Lateral neck film should be taken in patients with suspected epiglotttis or airway compromise. ‘+ Soff tissue neck CT can be used if concern for abscess or deep-space infection exists; however, peritonsillar abscess is almost always a clinical diagnosis. Imaging is rarely needed for diagnosis. @medicine Procedures ‘See the list below: ‘+The procedure for a throat swab is to vigorously rub a dry swab over the posterior pharynx and both tonsils, obtaining a sample of exudate. If any exudate is obtained, then transport it dry (not ina liquid medium). Treatment Prehospital Care ‘See the list below: ‘+ Prehospital care usually is not necessary for uncomplicated pharyngitis unless airway compromise is an issue. ‘+ Intubation should not be attempted unless the patient stops breathing spontaneously. Cmedicine Emergency Department Care ‘See the list below: ‘+ Assess and secure the airway, ifnecessary. ‘+ Assess the patient for signs of toxicity, epiglotttis, or oropharyngeal abscess (31) ‘+ Evaluate the hydration status because severe pharyneits limits oral intake. Appropriate measures to rehydrate should be initiated, including intravenous hydration. ‘+ Assess for GAS infection if clinically suspected. A suggested algorithm as is follows, © In general, patients should not be treated without a positive culture or positive rapid antigen detection test result because of increasing antibiotic resistance. Guidelines from the Infectious Diseases Society of America (IDSA) ‘and American Heart Association state that microbiologic confirmation (via a rapid antigen test or culture) is required for the diagnosis of GAS.[13, 7] © Perform rapid antigen detection test if GAS is clinically suspected based on history and physical examination. If positive, begin antibiotic therapy. Testing does not usually need to be performed on patients with acute pharyngitis. whose clinical and epidemiologic features do not suggest GAS as the etiology (Centor score 0-1), © Patients who are positive for all 4 Centor criteria can often be treated with antibiotics without antigen testing or cultures if rapid antigen testing is not available. © Its important to note that the Centor criteria can be used to identity cases of pharyngitis that are likely viral (score (0-1) and do not need antigen testing. Patients with a Centor score of 4 should have confirmation of GAS infection with an antigen test before being treated with antibiotics, unless such testing is unavailable. 2 Household contacts of patients with GAS infection or scarlet fever should be treated for a full 10 days of antibiotics without testing only if they have symptoms consistent with GAS.(7] Asymptomatic contacts should not be treated© Ifclinically doubtful or the above criteria are not met, itis best to await rapid antigen or culture results to initiate antibiotic therapy. A study by Cohen et al suggested that rules-based selective testing strategies for children with pharyngitis do not have a sufficient combination of sensitivity and specificity to determine which patients should be tested for group A streptococcal infection. Using an external validation cohort of 676 children, the investigators determined that none of the clinical prediction rules used in the study reached the investigators’ diagnostic accuracy target; specifically, a sensitivity and specificity of greater than 85% {32] medicine Consultations With a few exceptions, uncomplicated cases of pharyngitis should not require a consultation. Infectious disease specialists should be consulted in the case of unusual presentation or in the case of a patient who is immunocompromised. medicine Guidelines Guidelines Summary ‘The Choosing Wisely medical initiative picked the top guidelines from the Italian Panel of the National Guidelines for the Management of Acute Pharyngitis in Children, The chosen recommendations are as follows[33] Blood exams should not be performed Antibiotics should not be administrated unless microbiologic confirmation of streptococcal infection has been carried out Ifa throat culture is performed, susceptibility tests on isolates should not be executed The antibiotic course should not be shortened Because penicillin V is not available in Italy, amoxicilin (50 mg/kg/d in 2-3 doses orally) for 10 days is the first choice treatment Steroids should not be administered, to avoid masking a possible underlying severe condition medicine Medication Medication Summary GAS pharyngitis is usually a self-limited disease, and most signs and symptoms resolve spontaneously in 3-4 days. If ‘administered early, antibiotics can shorten the duration of the illness by up to 1 day, but the main reason they are given is for prevention of acute rheumatic fever [34] This rationale is being questioned by many as the incidence of acute rheumatic fever in the United States is extremely low. In addition, pain medications such as NSA\Ds or acetaminophen and steroids can alleviate the symptoms associated with GAS pharyngitis [35] Antibiotics do not prevent acute glomerulonephritis. Steroids may be used {or airway compromise and symptomatic relief {36] Antifungals and antivirals are used in certain rare cases with specialist ‘consultation. ‘randomized, double-blind study by Shephard et al suggested that lozenges containing flurbiprofen 8.75 mg can alleviate moderate to severe pharyngitis symptoms for 3-4 hours, whether or not the patient is suffering from a group A or C streptococcal infection {37] Astudy by Miller et al indicated that a mouth and throat spray containing the osmolyte ectoine is effective against acute pharyngitis and/or laryngitis, demonstrating good to very good tolerability and reducing cervical lymph node swelling to a significantly greater degree than saline lozenges. The prospective, controlled, nonrandomized trial included 95 patients [38] Astudy by Fleming-Dutra et al found that, based on the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, pharyngitis was responsible for 43 ambulatory antibiotic prescriptions por 1000 population in the United States, the third highest rate of such prescriptions for a single diagnosis (after sinusitis and suppurative otis media) [39, 40, 41] medicineAntibiotics Class Summary Empiric antimicrobial therapy must be comprehensive and should cover all lkely pathogens in the context of the clinical setting Antibiotics are indicated for clinically suspected and culture or antigen-verified GAS infection, They are effective in preventing heumatic fever if given within 9 days of the onset of pharyngitis. ‘Of note, some experts question the use of antibiotics for the treatment of GAS infection in the Western world because of the low prevalence of rheumatic fever. Some European guidelines for the treatment of pharyngitis only recommend antibiotics for Patients with culture-positive GAS pharyngitis who are high-risk for acute rheumatic fever or very il.{42] One study suggested that observation alone was most cost-effective strategy for GAS pharyngitis in children, and this strategy also had lower morbidity and mortality than antibiotic treatment groups.{43] For now, most experts and guidelines in the United States stil recommend treatment with antibiotics. it should be noted, however, that the risk of a serious antibiotic adverse effects is higher than the risk of developing acute rheumatic fever as a consequence of GAS pharyngitis in the United States. ‘Some support the use of cephalosporins instead of penicilin as first-line therapy for GAS.[44, 45] They cite literature that shows {greater eradication of the bacteria in the pharynx after treatment with a cephalosporin. No evidence suggests that this is alinically significant, and clinical guidelines stil advocate that peniciln is stil the drug of choice for GAS in the United States. There has never been a clinical isolate of GAS documented to be resistant to penicillin anywhere in the world [13] In cases of linical treatment failure of GAS pharyngitis after penicillin therapy, a cephalosporin or broader-spectrum penicilin (ampicilin- sulbactam) should be considered, but these instances are rare [31] Cephalosporins should be considered first-line therapy ifthe patient has a history of recent antibiotic usage, recurrent pharyngitis infection, or if a high failure rate of penicilin is documented in the community [48] Macrolide resistance of GAS varies widely from year to year and among different parts of the world from 5% to 97%. Patients should only be treated with a macrolide if a penicilin or cephalosporin type drug is nat an option. If a macrolide is used to treat GAS, patients should be followed closely for treatment failure, as very rare case reports describe acute rheumatic fever after GAS treatment with macrolides [47] ‘Some controversy exists regarding the treatment of carriers of GAS, These are patients who have a positive rapid antigen or ‘culture without symptoms of pharyngitis. It is believed that this carrier state does not lead to acute rheumatic fever or other ‘complications of GAS pharyngitis. Most carriers should not be treated; however, treatment should be considered in carriers with the following characteristics: = Recurrent pharyngitis without cough or congestion - Acute theumatic fever (ARF) or poststreptococcal glomerulonephritis outbreaks = GAS pharyngitis in closed community = Family history of ARF = Multiple documented GAS pharyngitis episodes within a family over several weeks despite therapy If carriers are treated, clindamycin for 10 days or IM penicillin plus 4 days of rifampin are recommended treatment options.{48] While some literature exists to support the use of a shorter course of antibiotic therapy for GAS pharyngitis, most international guidelines still recommend a 10-day course for most antibiotics (49] Penicillin G benzathine (Bicillin LA) Inhibits biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations reached, and most effective during stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Still is drug of choice in GAS pharyngitis because of its narrow spectrum of activity, low cost, and proven safety track record. IM penicillin is drug of choice in patients where compliance is an issue because of single dose. Penicillin VK (Beepen-VK) Inhibits the biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached. Most effective during stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Poor patient compliance due to dosing frequency and duration plagues this drug regimen. However, tid dosing is shown in some,studies to be as effective as gid dosing. For recurrent streptococcal infections, a combination of penicilin VK and rifampin may be used. Rifampicin, 20 mgikg/d for 4 d, is added to the standard 10-d treatment with penicillin. Amoxicillin (Amoxil, Biomox, Trimox) Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria. Associated with higher incidence of rash. No advantage over oral penicilin, but sometimes more acceptable to children because of taste. Some studies suggest that once-daily dosing of amoxicilin is adequate therapy for GABHS, but further studios ‘are needed to validate this treatment regimen. Cephalexin (Keflex) First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora. Used for skin infections or prophylaxis in minor procedures, Choice for patients who are sensitive for penicillin Azithromycin (Zithromax) This antibiotic has a higher cost but has a slightly higher effectiveness than erythromycin. Shorter course and one-a-day dosing make this a good altemative for patients who are allergic to penicilin Erythromycin (EES, Erythrocin, Ery-Tab) Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria (ag, M pneumoniae, C pneumoniae, Ahaemolyticus), which generally are not sensitive to penicilin. Indicated for patients allergic to penicilin. GABHS resistance is generally thought to be less than 5% in the United States, but more recent studies show resistance rates of up to 30%. Clindamycin (Cleocin) ‘Semisynthetic antibiotic produced by 7(S)-chloro-suistitution of 7(R)-hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Widely distributes in the body without penetration of CNS. Protein bound and excreted by the liver and kidneys. Used for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci), More effective than penicilin in eliminating chronic streptococcal carriage. Recommended for treatment of symptomatic people with multiple, recurrent episodes of GABHS pharyngitis confirmed by rapid antigen testing or culture. Ceftriaxone (Rocephin) ‘Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicilin-binding proteins Indicated for cases of gonococcal pharyngitis. Dosing is different for neonatal gonorrhea. medicine Corticosteroids Class Summary ‘Steroids have been shown to improve clinical symptoms in patients with pharyngitis, particularly in patients with severe or ‘exudative pharyngitis(50] Steroids are also used in cases of airway obstruction. They have been shown in several studies to reduce clinical symptoms and to shorten the clinical course.[51, 52] They should be used selectively for patients with significant swelling or odynophagia (36, 52]Dexamethasone (Decadron) Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reducing capillary permeability. For pharyngitis, steroids must be administered in conjunction with antibiotics. Provides symptomatic relief for severe pharyngitis. A ‘one-time IM dose is convenient and avoids compliance issues. Betamethasone is an alternative to dexamethasone. Prednisone (Deltasone, Orasone, Sterapred) May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Inactive and must be metabolized to the active metabolite prednisolone. The conversion may be impaired in patients with liver disease. medicine Antifungals Class Summary ‘These agents are indicated for cases of pharyngitis associated with oral thrush. Nystatin (Mycostatin) Fungicidal and fungistatic antibiotic obtained from Streptomyces noursei. Effective against various yeasts and yeastlke fungi Changes permeability of fungal cell membrane after binding to cell membrane sterols, causing cellular contents to leak ‘Treatment should continue until 48 h after disappearance of symptoms. Fluconazole (Diflucan) ‘Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal CYP-450 and sterol C-14 alpha- demethylation. medicine Follow-up Further Outpatient Care ‘See the list below: ‘+ Follow-up for GAS pharyngitis © standardized protocol needs to be established at each institution or ED to ensure follow-up for patients with, pending throat cultures. This is particularly challenging with unreliable patients and with a shift-dependent ED practice ‘© Whether or not they are given antibiotics, patients diagnosed with pharyngitis should follow up if symptoms do not improve within 72 hours. © Routine posttreatment throat cultures are unnecessary and may remain positive for several weeks [2] © follow-up culture should be taken if history or evidence of rheumatic fever or if symptoms are consistent with a relapse. (46) + Patients with infectious mononucleosis should be instructed to follow up with their physician in 1 week. These patients should also be advised to avoid contact sports.[17] + Viral pharyngitis generally requires no specific follow-up unless immunosuppression is suspected or symptoms worsen, ‘+ Patients with suspected malignancy should be referred to an otolaryngologist for followup.Cmedicine Further Inpatient Care ‘See the list below: ‘+ Inpatient care usually is not indicated except in cases such as epiglotitis, severe dehydration, deep-space infection, other airway compromise, or diphtheria, medicine Transfer ‘See the list below: ‘+ Transfer usually is not necessary for simple acute pharyngitis. ‘+The airway should be evaluated and endotracheal intubation should be performed prior to transfer ita high probability of compromise exists during transfer, medicine Deterrence/Prevention ‘See the list below: ‘+ Throat cultures should be obtained on close contacts of patients with a history of a nonsuppurative complication (acute rheumatic fever) of a streptococcal infection or if recurrent outbreaks of GAS pharyngitis occur [7] ‘+ Diphtheria immunization is highly effective and recommended for nonimmunized patients to reduce potential morbidity and mortality of the disease. medicine Complications ‘See the list below: + General complications of pharyngitis (mainly seen in cases of bacterial pharyngitis) include sinusitis, otitis media, epigiotitis, mastoiditis, and pneumonia. © Suppurative complications of bacterial pharyngitis result from spread of infection from pharyngeal mucosa via hematogenous, lymphatic, or direct extension (more common with GAS); peritonsillar abscess; retropharyngeal abscess; or suppurative cervical lymphadenitis, Itis unclear If antibiotic therapy can prevent these complications as abscess isolates are often polymicrobial. Many experts believe these are actually independent entities and not related to GAS pharyngitis. ‘+ In addition to the above general complications, nonsuppurative complications (3% incidence) specific to GAS infection include acute rheumatic fever (3-5 wk postinfection), poststreptococcal glomerulonephritis, and toxic shock syndrome. ‘+ Complications of infectious mononucleosis include splenic rupture (contact sports should be avoided for 6 wk), hepatitis, Guillain-Barré syndrome, encephalitis, hemolytic anemia, agranulocytosis, myocarditis, B-cell ymphoma, and nasopharyngeal carcinoma. Use of penicilin in cases of infectious mononucleosis results in near 100% incidence of rash. 07] medicine Prognosis ‘See the list below:‘+ Most cases of pharyngitis resolve spontaneously within 10 days, but it is important for the clinician to be aware of potential complications listed above. + Treatment failures are frequent and are attributed mainly to poor compliance, antibiotic resistance, untreated close contacts, carrier states, and antibiotic-related or copathogenic suppression of host immunity and necessary flora {5, 53) Of note, GAS resistance to penicillin is NOT thought to be a reason for treatment failures with penicilin. ‘+ Pationts should expect improvement in symptoms in penicillin-sensitive streptococcal pharyngitis within 24 hours of initiation of treatment. Contagious and often the febrile periods also are reduced to 1 day. It should be noted that pain ications and steroid use for pharyngitis are extremely effective for improving symptoms of pharyngitis [35] medicine Patient Education See the list below: + Patients must be instructed to complete the full course of antibiotic therapy, as improvement may occur rapidly, + Patients should be instructed to follow up when indicated (see Further Outpatient Care). ‘+ Patients with infectious mononucleosis should be instructed to avoid contact sports for a period of 6 weeks because of the possibilty of splenic rupture. + Patients should be educated about symptomatic treatment of pharyngitis. © Ibuprofen or acetaminophen is recommended for analgesia, © Saltwater gargle, warm liquids, and rest may be helpful in relieving symptoms, ‘+ For patient education resources, see the Infections Center. Also see the patient education articles Sore Throat and Mononucleosis. medicine Questions & Answers Overview What is pharyngitis (sore throat)? How are viral and bacterial causes of pharyngitis (sore throat) differentiated? What are the Centor criteria for group A streptococcal (GAS) pharyngitis (strep throat)? How is the Centor score for group A streptococcal (GAS) pharyngitis (strep throat) interpreted? What is included in the physical exam of pharynsitis (sore throat)? What is the role of lab studies in the diagnosis of pharyngitis (sore throat)? What isthe role of imaging studies in the diagnosis of pharyngitis (sore throat)? How is pharyngitis (sore throat) managed? What is included in treatment of pharyngitis (sore throat) in the emergency department (ED)? What are the treatment options for group A streptococcal (GAS) pharynsits (strep throat)? What are the causes of pharyngitis (sore throat)? What is the most common bacteria that causes pharyngitis (sore throat)? How is pharyngitis (sore throat) characterized? Aside from GAS (Streptococcus pyogenes), what other bacteria cause pharynaitis (sore throat)? What are the main concems in the emergency department (ED) regarding pharynaitis (sore throat)?What is the pathophysiology of pharyngitis (sore throat)? What are the characteristics of group A streptococcal (GAS) pharyngitis (strep throat)? What is the incidence of pharyngitis (sore throat) in the US? What is the global incidence of pharyngitis (sore throat)? What are complications of streptococcal pharyngitis (sore throat)? What is the mortality rate for pharyngitis (sore throat)? How does the prevalence of pharyngitis (sore throat) vary by age? Presentation What are the classic presentations of pharyngitis (sore throat)? What are the Centor criteria used to diagnose and treat group A streptococcal (GAS) pharyngitis (strep throat)? How are the Centor criteria scored for group A streptococcal (GAS) pharyngitis (strep throat)? What are the physical findings characteristic of pharyngitis (sore throat)? Which organisms cause bacterial pharyngitis (sore throat)? Which organisms cause viral pharyngitis (sore throat)? What are less common causes of pharyngitis (sore throat)? pox Which conditions should be included in the differential diagnoses of pharyngitis (sore throat)? What are the differential diagnoses for Pharyngitis? Workup How is group A streptococcal (GAS) pharyngitis (strep throat) diagnosed? What is the role of the group A beta-hemo}ytic streptococcal (GABHS) rapid antigen detection test in the diagnosis of pharyngitis (sore throat)? How accurate is the group A beta-hemolytic streptococcal (GABHS) rapid antigen detection test for the diagnosis of pharyngitis, {sore throat)? What are the benefits of the group A beta-hemolytic streptococcal (GABHS) rapid antigen detection test for the diagnosis of pharyngitis (sore throat)? What is the role of throat culture in the diagnosis of pharyngitis (sore throat)? What lab tests may be useful in the workup of pharyngitis (sore throat)? What is the role of imaging studies in the diagnosis of pharyngitis (sore throat)? How is a throat swab obtained for the diagnosis of pharyngitis (sore throat)? Treatment What prehospital care is needed for pharyngitis (sore throat)? What is included in emergency department (ED) care for pharyngitis (sore throat)? What is the reliability of selective testing strategies for the diagnosis of pharyngitis (sore throat)? When is specialist consultation needed for the management of pharyngitis (sore throat)? Guidlines What are the Choosing Wisely recommendations for the management of acute pharyngitis (sore throat) in children?Medications What is the role of osmolyte ectoine spray in the treatment of pharyngitis (sore throat)? ‘What is the role of medications in the treatment of pharyngitis (sore throat)? ‘What is the role of flurbiprofen lozenges in the treatment of pharyngitis (sore throat)? ‘What is the medication prescription history for pharyngitis (sore throat)? ‘Which medications in the drug class Antifungals are used in the treatment of Pharyngitis? Which medications in the drug class Corticosteroids are used in the treatment of Pharyngitis? Which medications in the drug class Antibiotics are used in the treatment of Pharyngitis? Follow-up ‘What monitoring is needed following treatment of pharyngitis (sore throat) in the emergency department? When is inpatient care indicated for pharyngitis (sore throat)? When is transfer indicated for treatment of pharyngitis (sore throat)? How is pharyngitis (sore throat) prevented? What are complications of pharyngitis (sore throat)? ‘What is the prognosis of pharyngitis (sore throat)? ‘What information about pharyngitis (sore throat) should patients receive? Cmedicine Contributor Information and Disclosures Author John R Acerra, MD Associate Professor, Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Director, Global Emergency Medicine Program, LIJ Medical Center and North Shore University Hospital, Northwell Health System John R Acerra, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Sociely for Academic Emergency Medicine Disclosure: Nothing to disclose. Specialty Eitor Board Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape. Chief Editor Jeter (Jay) Pritchard Taylor, ll, MD Assistant Professor, Department of Surgery, University of South Carolina Schoo! of Medicine; Attending Physician / Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Prisma Health Richland Hospital Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, ‘American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor - Chief Editor for Medscape. Additional ContributorsJerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Tachnology College of Osteopathic Medicine Jerry R Balentine, 00, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association Disclosure: Nothing to disclose. Acknowledgements Mark W Fourre, MD Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine; Program Director, Department of Emergency Medicine, Maine Medical Center Disclosure: Nothing to disclose. References 1. Sykes EA, Wu V, Beyea MM, Simpson MTW, Beyea JA. Pharyngitis: Approach to diagnosis and treatment. Can Fam Physician 2020 Apr. 66 (4):251-7. [QxMD MEDLINE Link]. [Full Text 2. Alcaide AL, Bisno AL. Pharyngitis and epiglotitis. Infect Dis Clin North Am. 2006, 21:449-469, 3. Twoflk TL, Al Garni M. Tonsilopharynaiis: Clinical highlights. J of Otolaryngology. 2005. 34: 4, Mostov PD, Treating the immunocompetent patient who presents with an upper respiratory infection: pharyngitis, sinusitis, and bronchitis. Prim Care, 2007 Mar. 34(1):39-58. [QxMD MEDLINE Link]. 5. Pichichero ME, Casey JR. Systematic review of factors contributing to penicilin treatment failure in Streptococcus pyogenes pharyngitis. Otolaryngol Head Neck Surg. 2007 Dec. 137(6):851-867. [QxMD MEDLINE Link]. 6. Banigo A, Moinie A, Bleach N, Chand M, Chalker V, Lamagni T. Have reducing tonsillectomy rates in England led to increasing incidence of invasive Group A Streptococcus infections in children’. Clin Otolaryngol. 2018 Mar 5, [QxMD MEDLINE Link} 7. [Guideline] Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute ‘Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Commitee of the Council on Cardiovascular Disease in the Young, the Interdsciplinary Council on Functional Genomics ‘and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrie. Circulation. 2009 Mar 24. 119(11):1841-51. [QxMD MEDLINE Link] £8. Centers for Disease Contral and Prevention. Summary of notifable diseases, United States, 1997. MMWR Morb Mortal Wkly Rep. 1988 Nov 20. 46(54):-vi, 3-87. [QxMD MEDLINE Link]. 9. Kalra MG, Higgins KE, Perez ED. Common Questions About Streptococcal Pharyngitis. Am Fam Physician. 2016 Jul 1. 94 (1):24-31 [QxMD MEDLINE Link} 410. Nishiyama M, Morioka I, Taniguchi-Ikeda M, eta. Clinical features predicting group A streptococcal pharyngitis in a Japanese paediatric primary emergency medical centre. J Int Med Res. 2018 Jan 1. 300060517752954. [QxMD MEDLINE Link}. [Full Text) 11. Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision ofthe signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr. 2012 Mar. 160(3):487-493.e3. [QxMD MEDLINE Link] 12. Centor RM, Alison JJ, Cohen SJ. Pharyngitis management: defining the controversy. J Gen Intern Med. 2007 Jan. 22(1):127-30. [QxMD MEDLINE Link}. 18, Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, etal. 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 Nov 15. 55(10):1278-82. [QxMD MEDLINE Link} 14. Wagner FP, Mathiason MA. Using centor criteria to diagnose streptococcal pharyngitis. Nurse Pract. 2008 Sep. 33(9):10-2. [QxMD MEDLINE Link 418. Melsaac Wi, Goel V, ToT, Low DE. The validity of a sore throat score in family practice. CMAJ. 2000 Oct 3. 163 (7):811-5. [xMD MEDLINE Lin} 416, Fine AM, Nizet V, Mandl KD, Large-scale validation of the Centor and Mclsaac scores to predict group A streptococcal pharynaits, ‘Arch Intern Med. 2012 Jun 11. 172 (11):847-52. [QxMD MEDLINE Link]. [Full Text] 17. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. 2005 Jun. §2(3):728-47, vi. [QxMD MEDLINE Link}18. 19. 20. 21 22. 23, 24. 25. 26. 21. 28. 29. 30, at 22. 33. 36. 36. a7. 39. Jo SA, Ma SH, Kim S. Diagnostic Impact of Clinical Manifestations of Group A Streptococcal Pharyngitis. Infect Chemother, 2021 ‘Sep. 83 (3):553-8. [QxMD MEDLINE Link]. [Full Text ‘Shapiro DJ, Barak-Corren Y, Neuman Ml, Mandl KD, Harper MB, Fine AM. Identying Patients at Lowest Risk for Streptococcal Pharyngitis: A National Validation Study. J Pediatr. 2020 May. 220:132-8.02. [OxMD MEDLINE Link) LLemierre's syndrome, reemergence of a forgotten disease: a case report. Cases J. 2008 Mar 10, 2:6397. [QxMD MEDLINE Link] (Full Text Goitlieb M, Long B, Koyfman A. Clinical Mimics: An Emergency Medicine Focused Review of Streptococcal Pharyngitis Mimics. J Emerg Med. 2018 Mar 6. [QxMD MEDLINE Link) Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigen-detection test and throat culture in community pediatric ofices: implications for management of pharyngitis. Pediatrics. 2009 Feb. 123(2):437-44. [QxMD MEDLINE Link. Cohen JF, Cohen R, Bidet P, et al, Efficiency of a clinical prediction model for selective rapid testing in children with pharyngitis: A Prospective, multicenter study. PLoS One, 2017, 12 (2):20172871. [QxMD MEDLINE Link) (Ful Tex Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev. 2004 Jul. 17 (3):571-80, table of contents. [QxMD MEDLINE Link]. Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigen-detection test and throat culture in community pediatric ofices: implications for management of pharyngitis. Pediatrics, 2009 Feb. 123 (2):437-44, [QxMD MEDLINE Link}. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2006 Oct 18. CD000023. [xMD MEDLINE Lin) Nakhoul GN, Hickner J. Management of adults with acute streptococcal pharyngitis: minimal value for backup strep testing and overuse of antibiotics. J Gen Intern Med. 2013 Jun. 28 (8):830-4, [QxMD MEDLINE Link) ‘Ayanruoh S, Waseem M, Que F, Humphrey A, Reynolds T. Impact of rapid streptococcal test on antibiotic use in a pediatric ‘emergency depariment. Pediatr Emerg Care. 2009 Nov. 25(11):748-50. [QxMD MEDLINE Link} Dingle TC, Abbott AN, Fang FC. Reflexive culture in adolescents and adults with group A streptococcal pharyngitis. Clin Infect Dis, 2014 Sep 1. 59 (5):643-50. [OxMD MEDLINE Link} Pelucchi C, Grigoryan L, Galeone ©, Esposito S, Huovinen P, Little P, et al, Guideline for the management of acute sore throat, Clin Microbiol Infect. 2012 Apr. 18 Suppl 1:1-28, [xMD MEDLINE Link) Patel NN, Patel DN, Acute exudative tonsilits. Am J Med. 2009 Jan. 122(1):18-20. [OxMD MEDLINE Link Cohen JF, Cohen R, Levy ©, ot al, Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: @ systematic review and prospective multicentre external validation sludy, CMAJ, 2015 Jan 6, 187(1):23-32, [QxMD MEDLINE Lin) (Full Text CChiappini €, Bortone B, Di Mauro G, et al. Choosing Wisely: The Top-5 Recommendations from the Italian Panel ofthe National {Guidelines for the Management of Acute Pharyngitis in Children. Clin Ther. 2017 Mar. 38 (3):648-9. (QxMD MEDLINE Link]. - Del Mar CB, Glasziou PP, Spinks AB, Antibiotics for sore throat (Review), The Cochrane Collaboration, 2007, (1):1-41, Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012 Oct 17. 10:CD008268. [QxMD MEDLINE Link]. Tasar A, Yanturali S, Topacoglu H, Ersoy G, Unverr P, Sarikaya S. Clinical eficacy of dexamethasone for acute exudative pharyngitis. J Emerg Med. 2008 Nov. 36(4):36-7. [QxMD MEDLINE Link]. Shephard A, Smith G, Aspley S, ot al. Randomised, double-blind, placebo-contralled studies on flurbiprofen 8.75 mg lozenges in patients withwithout group A or © streptococcal throat infection, with an assessment of clinicians’ prediction of ‘strep throat Int J (lin Pract. 2015 Jan. 69(1):59-71. [QxMD MEDLINE Link} Muller D, Lindemann T, Shah-Hosseini K, etal Efficacy and tolerability of an ectoine mouth and throat spray compared with those of saline lozenges in the treatment of acute pharyngitis and/or laryngitis: a prospective, controlled, observational clinical tial. Eur Arch Otorhinolaryngol. 2016 Apr 28. [QxMD MEDLINE Link} Fleming-Dutra KE, Hersh AL, Shapiro D4, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011, JAMA, 2016 May 3, 315 (17):1864-73, [QxMO MEDLINE Link} Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989- 1989. JAMA, 2001 Sep 12. 286 (10):1181-6. [QxMD MEDLINE Link].at 42. 43. 44, 45. 46, 47. 49. 51 82. 56. Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997-2010. JAMA Intern Med, 2014 Jan, 174 (1):138-40. [QxMD MEDLINE Link} Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among intemational pharyngitis guidelines: not ust academic. Ann Fam Med. 2007 Sep-Oct. 5(5):436-43. [QxMD MEDLINE Link]. Van Howe RS, Kusnier LP 2nd. Diagnosis and management of pharyngitis in a pediatric population based on cost-effectiveness and projected heath outcomes. Pediatrics. 2006 Mar. 117(3):609-18. [QxMD MEDLINE Link] Pichichero ME. Pathogen shits and changing cure rates for otis media and tonsilopharyngits. Clin Pediatr (Phila). 2006 ul 45(6):493-502, [QxMD MEDLINE Link]. Pichichero M, Casey J. Comparison of European and U.S. results for cephalosporin versus penicilin treatment of group A streptococcal tonsilopharyngits. Eur J Clin Microbiol Infect Dis. 2006 Jun. 25(6):354-64, [xMD MEDLINE Lin Brook |, Overcoming penicilin failures inthe treatment of Group A streptococcal pharyngo-tonsilitis, Int J Pediatr Otorhinolaryngol 2007 Oct, 71(10):1501-8. [QxMD MEDLINE Link Logan LK, McAuley JB, Shulman ST. Macrolide treatment failure in streptococcal pharyngitis resuling in acute rheumatic fever. Pediatrics. 2012 Mar. 128(3):e798-802. [QxMD MEDLINE Link} Depdham D, Rao S, Hitchcock K. Should you treat carriers of pharyngeal group A strep? J Fam Pract, 2008. 87: Altamimi S, Khalil A, Khalaiwi KA, Miner R, Pusic MV, Al Othman MA. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. 2009 Jan 21. CD004872. [QxMD MEDLINE Link}. . Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Ann Fam Med. 2010 Jan-Feb. 8(1):58-63. [QxMD MEDLINE Link]. (Full Text) Hayward G, Thompson M, Heneghan ©, Perera R, Del Mar C, Glasziou P. Corticosteroids for pain relief in sore throat: systematic, review and meta-analysis. BMJ. 2009 Aug 6. 339:62976. [QxMD MEDLINE Link]. [Full Tex) Wing A, Villa-Roel C, Yeh B, Eskin B, Buckingham J, Rowe BH. Effectiveness of Corticosteroid Treatment in Acute Pharyngitis: A ‘Systematic Review ofthe Literature, Acad Emerg Med, 2010. 17(5):476-483, Rick AM, Zaheer HA, Martin JM. Clinical Features of Group A Streptococcus in Children With Pharyngitis: Carriers versus Acute Infection, Peciatr Infect Dis J, 2020 Feb 7, [QxMD MEDLINE Link]. ‘Boggs W. What antibiotic strategy is best for adults with acute sore throat? Medscape Medical News. January 27, 2014; Accessed February 4, 2014, Available at hitp:/www.medscape.com/viewarticle/820008. Huttner B. Antibiotic prescr {or sore throat or the legacy of Mr X2.. Lancet Infect Dis. 2014 Jan 16. [QxMD MEDLINE Link} Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Delaney B, etal. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect Dis. 2014 Jan 16. [QxMD MEDLINE Link}