Evaluation and Management of Patients With Pharyngitis in Urgent Care (Pharmacology CME)

Table of Contents

 

About This Course

Pharyngitis is a common complaint with a broad differential; although the cause is most often a viral infection, patients who present with sore throat must be screened for more concerning etiologies, including bacterial or fungal infections. The most frequent bacterial cause of pharyngitis is group A beta-hemolytic Streptococcus (GABHS), or “strep throat,” which carries a risk of suppurative complications and acute rheumatic fever. The increasing use of POC NAAT testing has made testing for GABHS more expedient, but testing is not warranted in every case. If GABHS pharyngitis is diagnosed, antibiotics are indicated. This issue of Evidence-Based Urgent Care reviews the evidence-based recommendations for the evaluation and management of pharyngitis in the urgent care setting, including:

What are the key history and physical examination findings that can help to distinguish viral pharyngitis from GABHS pharyngitis or other etiologies?

Which clinical findings raise suspicion for more dangerous etiologies of sore throat? How should those etiologies be managed?

When is testing for GABHS indicated, and which type of test is most appropriate?

What are the potential complications of GABHS pharyngitis?

When are antibiotics needed?

What are the best options for pain control in acute pharyngitis?

Do corticosteroids have a role in the management of pharyngitis?

How do the elements of medical decision making help to determine the appropriate level of service code for an encounter with a patient with pharyngitis?

1. About This Course
2. Abstract
3. Case Presentations
4. Introduction
5. Etiology and Pathophysiology
6. Differential Diagnosis
7. Urgent Care Evaluation
   1. History
   2. Physical Examination
   3. The Centor Criteria
8. Diagnostic Studies
   1. Nucleic Acid Amplification Testing
   2. Rapid Antigen Detection Testing/Throat Culture
   3. Other Laboratory Testing
9. Treatment
   1. Treatment With Antibiotics
   2. Pain Relief
10. Special Circumstances
    1. Patient Expectations for Antibiotics
    2. Fusobacterium and Lemierre Syndrome
    3. Chronic Group A Beta-Hemolytic Streptococcus Carriers
11. Controversies and Cutting Edge
    1. Withholding Antibiotics for Group A Beta-Hemolytic Streptococcus
    2. Antibiotics to Prevent Complications
       1. Acute Rheumatic Fever
       2. Suppurative Complications
    3. Treatment With Corticosteroids
    4. Indications For Tonsillectomy
12. Disposition
13. 5 Things That Will Change Your Practice
14. Summary
15. KidBits: Diagnostic Studies for Pharyngitis in Young Children
16. Time- and Cost-Effective Strategies
17. Critical Appraisal of the Literature
18. Risk Management Pitfalls for Urgent Care Management of Pharyngitis
19. Case Conclusions
20. Clinical Pathway for Managing Pharyngitis in Urgent Care
21. References

Abstract

Sore throat is one of the most common presenting complaints in outpatient medicine, so urgent care clinicians must be experts in evaluating and treating patients with pharyngitis. The differential diagnosis for pharyngitis is broad and includes a few serious disease processes that must be quickly ruled out. This issue reviews international guidelines for pharyngitis and discusses controversies and recent advances in diagnostic and treatment strategies, specifically for management of suspected bacterial and viral etiologies.

Case Presentations

A 2-and-a-half-year-old girl with a sore throat is brought to UC by her mother...

• The patient refuses to eat and has been complaining of pain for 2 days; her mother reports that she has had “low-grade” fevers.
• The girl does not attend daycare. She looks well overall and is drinking from a juice box in the examination room.
• The patient’s mother asks you to prescribe an antibiotic for the child's “strep throat.”
• You wonder if antibiotics are the appropriate management choice for this patient…

A 20-year-old man presents to UC complaining of 2 days of sore throat…

• He is febrile with a temperature of 38.4° C. He 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.
• You wonder whether any testing is needed for this patient, and how you should treat him…

A 35-year-old woman with 6 days of sore throat presents with voice changes...

• She describes a change of intonation but no hoarseness.
• She looks well but insists her voice sounds quite different. She has odynophagia without any other associated symptoms.
• You wonder if this patient needs urgent intervention…

A 62-year-old man arrives after several weeks of sore throat and hoarseness...

• He states that he has not had a fever or other upper respiratory symptoms, and has no known exposures, but his primary symptoms have been gradually worsening. He is a smoker.
• You wonder if this could be a noninfectious etiology…

Clinical Pathway for Managing Pharyngitis in Urgent Care

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. Chow AW, Doron S. Evaluation of acute pharyngitis in adults. 2020. Updated August 24, 2022. Accessed September 10, 2022. (Review)

8. * Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev. 2021;12(12):CD000023. (Systematic review; 15,337 patients) DOI: 10.1002/14651858.CD000023.pub5

11. * Shulman ST, Bisno AL, Clegg HW, et al. 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;55(10):1279-1282. (Guideline) DOI: 10.1093/cid/cis847

12. * ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, et al. Guideline for the management of acute sore throat. Clin Microbiol Infect. 2012;18 Suppl 1:1-28. (Guideline) DOI: 10.1111/j.1469-0691.2012.03766.x

41. * Centor RM, Witherspoon JM, Dalton HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-246. (Prospective study; 286 patients) DOI: 10.1177/0272989X8100100304

48. * Snow V, Mottur-Pilson C, Cooper RJ, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med. 2001;134(6):506-508. (Guideline) DOI: 10.7326/0003-4819-134-6-200103200-00018

55. * Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001;134(6):509-517. (Guideline) DOI: 10.7326/0003-4819-134-6-200103200-00019

107. American Medical Association. CPT^® evaluation and management (E/M) office or other outpatient (99202-99215) and prolonged services (99354, 99355, 99356, 99417) code and guideline changes. 2021. Accessed September 10, 2022. (Summary of coding guidelines)

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Keywords: sore throat, pharyngitis, strep throat, streptococcal pharyngitis, group A beta-hemolytic Streptococcus, GABHS, GAS, Fusobacterium, mononucleosis, gonococcal pharyngitis, syphilitic pharyngitis, F necrophorum, NAAT, RADT, throat culture, Epstein-Barr virus, scarlet fever, acute rheumatic fever, antibiotics, Centor score, nucleic acid amplification testing, Lemierre syndrome, peritonsillar abscess, Ludwig angina, corticosteroids, tonsillectomy