Pharyngitis
Red flags
Red flags
- Drooling/Secretions
- Dysphonia
- Dysphagia
- Muffled "hot potato" voice
- Neck swelling
Dangerous conditions (consider if red flags)
Dangerous conditions (consider if red flags)
- Submandibular space infections (Ludwig's angina - woody induration, crepitus)
- Primary HIV (mucocutaneous ulcerations)
- Peritonsillar abscess (trismus)
- Epiglottitis (out of proportion to findings on exam)
- Retropharyngeal space infection
If do not improve within 5-7 days or worsening symptoms, consider
- Infectious mononucleosis (fever, pharyngitis, fatigue, lymphadenopathy, splenomegaly, palatal petechiae)
- Consider WBC, AST, ALT, Monospot (or EBV serologies)
- Wait minimum of 4 weeks after illness onset for contact-sports (wait 3w if non-contact)
- HIV, Gonorrhea
- CMV, toxoplasmosis
- Suppurative complication (peritonsillar abscess)
- Infectious thrombophlebitis of the internal jugular vein (Lemierre's)
- Fusobacterium necrophorum (in 15-30yo)
Diagnosis
Diagnosis
- CENTOR: Cough absent Exudate/erythema tonsils, Neck nodes, Temp, Range of age (3-14=+1, 15-45=0, >45=-1)
- If CENTOR ≥3 (>30%): Rapid Antigen Detect Test (RADT) and/or culture
- Negative RADT consider throat culture back-up in children or immunocompromised (sensitivity 86%)
- Positive RADT do not need back-up culture (specificity 96%)
Not indicated to test
- <3 years old (unless high risk factor, eg. older sibling with GAS infection)
- CENTOR 0-1, Viral features (rhinorrhea, cough, oral ulcers, hoarseness)
Treatment
Treatment
- Symptomatic
- Acetaminophen/NSAIDs
- Topical (Benzocaine 10mg lozenge q2h PRN, Benzydamine 0.15% 15mL gargle q3h PRN)
- Consider Dexamethasone 0.6mg/kg (max 10mg) PO x 1 (NNT 12)
- If strep culture positive (or rapid strep positive), consider antibiotics (NNT 4 if positive strep throat, NNT 14 if no swab taken)
- Penicillin V (50mg/kg/day ÷ BID) 600mg PO BID x 10d
- Can consider Pen V QID x 5d
- Pediatrics: Amoxicillin 50 mg/kg PO daily (max 1g) x 10d
- If allergic
- If not anaphylactic, first generation cephalosporin
- Cephalexin (50mg/kg/day ÷ BID) 500mg PO BID x 10 days
- If anaphylactic
- Clarithromycin (15mg/kg/day ÷ BID) 250mg PO BID x 10d
- If not anaphylactic, first generation cephalosporin
- Penicillin V (50mg/kg/day ÷ BID) 600mg PO BID x 10d
Return To School
Return To School
- After full dose of amoxicillin, 91% of children the next morning had negative RADT/culture
- Consider returning to school on Day 2 of antibiotics if improved/afebrile
References:
- INESSS 2016. http://www.inesss.qc.ca/publications/clinical-guides-in-antibiotic-treatment-1st-series.html
- ACP 2016. http://annals.org.proxy3.library.mcgill.ca/aim/article/2481815/appropriate-antibiotic-use-acute-respiratory-tract-infection-adults-advice-high
- EMCrit 2015. http://rebelem.com/patients-strep-throat-need-treated-antibiotics/
- Ped Inf Dis J 2015. https://www.ncbi.nlm.nih.gov/pubmed/26295745
- Cochrane 2013. http://www.cochrane.org/CD000023/ARI_antibiotics-people-sore-throats
- IDSA 2012. https://academic.oup.com/cid/article-lookup/55/10/e86
- CPS 2011. https://www.cps.ca/en/documents/position/Invasive-group-A-streptococcal-disease