Pharyngitis is a common presentation, but it can also be associated with life-threatening processes, including sepsis and airway compromise. Other conditions, such as thyroid disease and cardiac disease, may mimic pharyngitis. The emergency clinician must sort through the broad differential for this complaint using a systematic approach that protects against early closure of the diagnosis. This issue reviews the various international guidelines for pharyngitis and notes controversies in diagnostic and treatment strategies, specifically for management of suspected bacterial, viral, and fungal etiology. A management algorithm is presented, with recommendations based on a review of the best available evidence, taking into account patient comfort and outcomes, the need to reduce bacterial resistance, and costs.
You are working in a community emergency department when a first-time mother brings in her two-and-a-half-year-old daughter who has had a sore throat for 2 days. She has had low-grade fevers and will not eat, complaining of pain. She is not in daycare, looks well overall, and is drinking from a juice box in the examination room. Mom is asking for antibiotics for strep throat and you think to yourself, “Is this an appropriate patient to give antibiotics to?”
The next patient you see is a 20-year-old man who has had a sore throat for 2 days. He is febrile to 38.8°C, has bilateral tonsillar erythema and exudates, and tender cervical adenopathy. He has not been coughing, is able to eat and drink, and does not have any trouble breathing, but he is asking for pain medication. What should you give him? Does he need a test for strep? If so, which one? Does he need antibiotics? If so, what kind? Later that day, you see a 35-year-old woman with 5 days of sore throat, presenting with voice changes. She looks well, but she but swears her voice is not normally this hoarse, and she has odynophagia without any other associated symptoms. Could this be a life-threatening cause of sore throat? Does she need an urgent intervention?
Your last patient is a 65-year-old male smoker complaining of several weeks of sore throat and hoarseness. He has not had a fever or other upper respiratory symptoms. He does not have any known exposures, and reports a gradual worsening of symptoms. You think to yourself, “What is the chance this is not infectious?” What other etiologies should you consider in this patient with sore throat?
Pharyngitis is the combination of sore throat, fever, and pharyngeal inflammation,1 and it is one of the most common chief complaints seen in the emergency department (ED). Sore throat accounted for over 2 million ED visits in 2007.2 Emergency clinicians must be able to assess these patients for airway threats and determine an efficient treatment strategy.
This simple presentation is still the cause of much debate and practice variation, with conflicting guidelines for care. The crux of the pharyngitis debate centers around group A beta hemolytic Streptococcus (GABHS), or “strep throat,” which accounts for 20% to 30% of sore throat visits in children3,4 and 5% to 15% of sore throat visits in adults.5 It is estimated that, in the United States, between $224 million and $539 million are spent annually on GABHS in children and adolescents,6 not including the costs for the adult cases. This infection has been known to cause both suppurative complications (eg, peritonsillar abscess or otitis media) and systemic complications (eg, acute rheumatic fever or glomerulonephritis).7-9 The incidence of suppurative complications and acute rheumatic fever are thought to have been reduced by antibiotic use, and they remain a primary consideration for diagnosis and treatment.10 However, as the incidence of acute rheumatic fever has declined greatly in the United States and other developed countries, the importance of treatment to prevent this complication has come into question.11
This leads to many questions that the emergency clinician must be able to answer, including: Does this patient have strep throat? Are antibiotics needed? What else, if anything, can we use to treat pain? Supplemental questions to those basics include: Could this be something dangerous, such as epiglottitis or a deep neck space infection? Are there other pathogens such as group C Streptococcus or Fusobacterium spp that we should be treating with antibiotics?12
While many guidelines exist, including the Infectious Diseases Society of America (IDSA) guidelines from 2012, the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) guideline from 2012, the American Heart Association/American Academy of Pediatrics (AHA/AAP) guideline, and the Centers for Disease Control and Prevention/American Academy of Family Physicians/American College of Physicians (CDC/AAFP/ACP) guideline from 2001, the recommendations conflict, causing confusion about best practices, and this contributes to broad practice variability.13 This issue of Emergency Medicine Practice provides a systematic review of the literature in order to provide clarity for best practice.
A literature search was performed on PubMed using the search terms: pharyngitis, tonsillitis, pharyngotonsillitis, streptococcal pharyngitis, and acute rheumatic fever. Titles, abstracts, and full articles were reviewed for content. The National Guideline Clearinghouse (www.guideline.gov) was also searched using the terms pharyngitis and sore throat and, within the practice guidelines, primary sources of literature were reviewed. The Cochrane Database of Systematic Reviews was also referenced using the terms pharyngitis and sore throat. Excluded articles included those regarding sore throat secondary to intubation. Important practice guidelines reviewed included the IDSA publication on streptococcal pharyngitis, the AHA/AAP publication on rheumatic fever and streptococcal pharyngitis, the ESCMID publication of acute sore throat, and the CDC/AAFP/ACP combined practice guideline on principles for appropriate antibiotic use in acute pharyngitis in adults.
These guidelines attempt to be evidence-based, but they fall to consensus for deciding which patients to test and treat (arguably their most important sections), which leads to discrepancies between them. While the literature is rich in studies on group A Streptococcus, monitorrapid antigen detection tests (RADTs), and different treatments for pharyngitis, data are lacking on acute rheumatic fever in the developed world, as its prevalence has sharply declined. Data on other causes of bacterial pharyngitis (eg, groups C and G Streptococcus and Fusobacterium spp) are also limited, as they have been thought to be inconsequential. Recent data on suppurative complications from GABHS are also lacking, as most of the data come from studies done prior to 1975, and it is unknown how these results apply to current conditions.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.
Amy F. Hildreth, MD; Sukhjit Takhar, MD, MS
September 1, 2015
August 31, 2018
Upon completion of this article, participants should be able to:
Physician CME Information
Date of Original Release: September 1, 2015. Date of most recent review: August 10, 2015. Termination date: September 1, 2018.
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Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 1 Pharmacology CME credit, subject to your state and institutional approval.
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Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical presentations; and (3) describe the most common mediocolegal pitfalls for each topic covered.
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