Pharyngitis: Signs and Symptoms

2/19/2019 https://emedicine.medscape.
com/article/764304-print

emedicine.medscape.com
Pharyngitis
Updated: Apr 11, 2018
Author: John R Acerra, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD
Overview
Practice Essentials
Pharyngitis is defined as an infection or irritation 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 streptococci (GAS). Other causes include allergy, trauma, toxins, and neoplasia.
Posterior pharynx with petechiae and exudates in a 12yearold girl. Both the rapid antigen detection test and throat culture were positive for group A betahemolytic
streptococci.
Signs and symptoms
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It is difficult 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 47 years
Sudden onset is consistent with GAS pharyngitis; pharyngitis after several days of coughing or rhinorrhea is more consistent with a viral etiology
Contact with others who have GAS or rheumatic 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
A history 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)
A score of 01 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
See Clinical Presentation for more detail.
Diagnosis
Laboratory studies that may be helpful include the following:
Group A betahemolytic streptococcal rapid antigen detection test (preferred diagnostic method in emergency settings)
Throat culture (criterion standard for diagnosis of GAS infection [9099% 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 film in patients with suspected epiglottitis or airway compromise
Softtissue neck CT if concern for abscess or deepspace infection exists
A 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, if necessary
Assess the patient for signs of toxicity, epiglottitis, 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 selflimited. 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
Patients who are positive for all 4 Centor criteria can often be treated with antibiotics without antigen testing or cultures
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
If the 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 selflimiting for the most part. Bacterial causes of pharyngitis are also selflimiting, but are concerning because of suppurative and nonsuppurative
complications. Other causes include allergy, trauma, toxins, and neoplasia.[1]
The most significant bacterial agent causing pharyngitis in both adults and children is GAS infection (Streptococcus pyogenes); this is shown in the image below.
Streptococcus pyogenes at 100X magnification.
Physical findings of GAS are shown in the image below.
Posterior pharynx with petechiae and exudates in a 12yearold girl. Both the rapid antigen detection test and throat culture were positive for group A betahemolytic
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.[2]
The main ED concerns with pharyngitis are to rule out more serious conditions, such as epiglottitis or peritonsillar abscess, and to diagnose group A betahemolytic
streptococcal (GABHS) infections. Airway obstruction is also of utmost importance for the ED physician treating pharyngitis.
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 irritation of pharyngeal mucosa secondary to nasal secretions.[2]
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 glomerulonephritis may result from antibodyantigen complex deposition in glomeruli.[3]
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 most
common viruses are rhinovirus and adenovirus. GAS is most prevalent in late fall through early spring.[1]
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 penicillin anywhere in the world.[4]
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 tonsillitis and pharyngitis and with an increase in invasive group A betahemolytic streptococcal
(GABHS) infections. Indeed, over the course of the 1990/1991 to 2013/2014 period, the number of invasive GABHS infections rose more than twofold in children aged 14
years or younger.[50]
Mortality/Morbidity
In the developing world, an estimated 20 million people are affected by acute rheumatic fever and rheumatic heart disease, making this the leading cause of cardiac death
during the first 5 decades of life. This incidence of rheumatic heart disease is dramatically 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.[5] The US Centers for Disease Control and Prevention (CDC)
stopped tracking the incidence of rheumatic heart disease in the United States in 1994, when the incidence dropped to less than 1 case per million US general population.
[6]
Other sequelae of streptococcal pharyngitis include acute glomerulonephritis, peritonsillar abscess, and toxic shock syndrome.
Mortality from pharyngitis is rare but may result from one of its complications, most notably airway obstruction.
Age
Pharyngitis occurs with much greater frequency in the pediatric population. Approximately 1530% of sore throats in children are caused by group A betahemolytic
streptococcal (GABHS) infections, compared with 515% of adults.[1, 7]
The peak incidence of bacterial and viral pharyngitis occurs in the schoolaged child aged 47 years, with GABHS occurring primarily in patients aged 515 years.
Pharyngitis, especially GAS infection, is rare in children younger than 3 years.
In a 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.[49]
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.[8] Despite this, classic presentations are described below.
GAS infection is most common in children aged 47 years.
Sudden onset is consistent with a GAS pharyngitis. Pharyngitis following several days of coughing or rhinorrhea 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 pharyngitis.
A history of recent orogenital contact suggests the possibility of gonococcal pharyngitis.
A history 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.[9] These include the following:
Fever
Anterior cervical lymphadenopathy
Tonsillar exudate
Absence of cough
One point is awarded for each of the criteria met, with patients scoring 01 unlikely to have GAS infection and patients with a score of 4 more likely to have GAS. A clinical
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.[10] In adults, the positive predictive value of the Centor
criteria for predicting GAS pharyngitis is around 40% if 3 criteria are met, and about 50% if 4 criteria are met.[11] These criteria along with other clinical features should be
used to guide treatment for pharyngitis in adults. A modified version of the Centor score, in which age is also taken account (and which is also called the McIsaac score),
can be used in diagnosis as well.[12, 13]
Physical
See the list below:
Airway patency must be assessed and addressed first.
Temperature: Fever is usually absent or lowgrade 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.
Scleral 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.
A tonsillopharyngeal 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
(handfootandmouth 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 fever.
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
A sandpapery scarlatiniform rash is seen in GAS infection (see Scarlet Fever).[14]
Maculopapular rashes are seen with various viral infections and with infectious mononucleosis empirically treated with penicillin.
Causes
See the list below:
Bacterial pharyngitis
Group A betahemolytic 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.[14]
Group C, G, and F streptococci may be indistinguishable clinically from GAS infection. Acute glomerulonephritis 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 foodborne outbreaks. The benefit of antibiotic therapy with
these types of streptococci is unproven at this time.[5]
Arcanobacterium (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 clinical picture similar to that of M pneumoniae. Pharyngitis usually precedes the pulmonary infection by about 13 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 foulsmelling graywhite pharyngeal membrane may result in airway obstruction.
Viral pharyngitis[3]
Adenovirus: The distinguishing feature of an adenovirus infection is conjunctivitis associated with pharyngitis (pharyngoconjunctival fever). It is the most
common etiology in children younger than 3 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, it is known
as lymphonodular pharyngitis. Coxsackievirus A16 may cause handfootandmouth disease, which presents with 4 to 8mm oropharyngeal ulcers and
vesicles on the hands and feet, and, occasionally, on the buttocks. The oropharyngeal ulcers and vesicles resolve within 1 week.
EpsteinBarr virus (EBV): Clinically known as infectious mononucleosis, it is 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.
HIV1: 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.
A rare but lifethreatening 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 million, but it should be considered when a critically ill patient presents with pharyngitis.[15]
DDx
Diagnostic Considerations
These include the following[51] :
Allergic rhinitis with postnasal drip
Airway obstruction
Head and neck neoplasias
Gastroesophageal reflux disease (GERD)
Peritonsillar cellulitis
Differential Diagnoses
Candidiasis in Emergency Medicine
Diphtheria
Emergent Management of Croup (Laryngotracheobronchitis)
Emergent Management of Gonorrhea
Emergent Management of Pediatric Epiglottitis
Epiglottitis
HandFootandMouth Disease in Emergency Medicine
Herpes Simplex in Emergency Medicine
Mononucleosis in Emergency Medicine
Pediatric Pharyngitis
Peritonsillar Abscess in Emergency Medicine
Pharyngitis
Pneumonia, Mycoplasma
Retropharyngeal Abscess
Rheumatic Fever in Emergency Medicine
Scarlet Fever
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 followup. (See the image below.)
Rapid antigen detection test for group A betahemolytic streptococci.
Only patients with a high clinical likelihood of GAS pharyngitis should be tested. Patients with a Centor score of 01 should be treated symptomatically without testing.[16]
(On the other hand, in a multicenter, prospective, crosssectional study, Cohen et al suggested that all children with pharyngitis undergo the rapid antigen detection test for
GAS, stating that assessment of signs and symptoms is an inefficient means of determining in which patients the test should be used.[17] )
Antigens are specific, but sensitivities vary. The sensitivity of the GABHS rapid antigen detection test is 7090%, and the specificity is 90100%, depending on the
manufacturer.[18, 19, 20, 21] Children with a negative antigen test should have a followup culture unless the antigen being used in the office has been shown to be as
sensitive as a culture.[14]
The use of a GABHS rapid antigen detection test can decrease the use of unnecessary antibiotics in pediatric patients when used properly.[22]
Adults do not need followup culture after a negative antigen test because of the low incidence of GAS in this population.[10]
Throat culture
This is the criterion standard for diagnosis of GAS infection (9099% sensitive).[52] Although less expensive than the rapid antigen detection test, it is not be the best test
to use in the emergency department because of difficulty with followup. The guidelines that recommend cultures for GAS screening are aimed at officebased 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 followup should a culture become positive.[1]
Other
Additional tests include the following:
Mono spot is up to 95% sensitive in children (less than 60% sensitivity in infants)
Peripheral smear may show atypical lymphocytes in infectious mononucleosis [2]
Perform gonococcal culture as indicated by history
A complete blood count (CBC), erythrocyte sedimentation rate (ESR), and Creactive protein have a low predictive value and usually are not indicated [23]
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 epiglottitis or airway compromise.
Soft tissue neck CT can be used if concern for abscess or deepspace infection exists; however, peritonsillar abscess is almost always a clinical diagnosis. Imaging
is rarely needed for diagnosis.
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 in a 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.
Emergency Department Care
See the list below:
Assess and secure the airway, if necessary.
Assess the patient for signs of toxicity, epiglottitis, or oropharyngeal abscess.[24]
Evaluate the hydration status because severe pharyngitis 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.[10, 5]
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 01).
Patients who are positive for all 4 Centor criteria can often be treated with antibiotics without antigen testing or cultures.
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.[5] Asymptomatic contacts should not be treated.
If clinically doubtful or the above criteria are not met, it is best to await rapid antigen or culture results to initiate antibiotic therapy.
A study by Cohen et al suggested that rulesbased 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%.[25]
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.
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[26] :
Blood exams should not be performed
Antibiotics should not be administrated unless microbiologic confirmation of streptococcal infection has been carried out
If a 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, amoxicillin (50 mg/kg/d in 23 doses orally) for 10 days is the first choice treatment
Steroids should not be administered, to avoid masking a possible underlying severe condition
Medication
Medication Summary
GAS pharyngitis is usually a selflimited disease, and most signs and symptoms resolve spontaneously in 34 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.[27] 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 NSAIDs or acetaminophen and steroids can alleviate the
symptoms associated with GAS pharyngitis.[28] Antibiotics do not prevent acute glomerulonephritis. Steroids may be used for airway compromise and symptomatic relief.
[29] Antifungals and antivirals are used in certain rare cases with specialist consultation.
A randomized, doubleblind 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.[30]
A study by Müller 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.[31]
A study by FlemingDutra et al found that, based on the 20102011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care
Survey, pharyngitis was responsible for 43 ambulatory antibiotic prescriptions per 1000 population in the United States, the third highest rate of such prescriptions for a
single diagnosis (after sinusitis and suppurative otitis media).[32, 33, 34]
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Antibiotics are indicated for clinically
suspected and culture or antigenverified GAS infection. They are effective in preventing rheumatic 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 culturepositive GAS pharyngitis who are highrisk for acute rheumatic
fever or very ill.[35] One study suggested that observation alone was most costeffective strategy for GAS pharyngitis in children, and this strategy also had lower morbidity
and mortality than antibiotic treatment groups.[36] For now, most experts and guidelines in the United States still 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 penicillin as firstline therapy for GAS.[37, 38] They cite literature that shows greater eradication of the bacteria in the
pharynx after treatment with a cephalosporin. No evidence suggests that this is clinically significant, and clinical guidelines still advocate that penicillin is still 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.[10] In cases of clinical
treatment failure of GAS pharyngitis after penicillin therapy, a cephalosporin or broaderspectrum penicillin (ampicillinsulbactam) should be considered, but these
instances are rare.[24] Cephalosporins should be considered firstline therapy if the patient has a history of recent antibiotic usage, recurrent pharyngitis infection, or if a
high failure rate of penicillin is documented in the community.[39]
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
penicillin or cephalosporin type drug is not 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.[40]
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 rheumatic 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.[41]
While some literature exists to support the use of a shorter course of antibiotic therapy for GAS pharyngitis, most international guidelines still recommend a 10day course
for most antibiotics.[42]
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 (BeepenVK)
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 qid dosing. For recurrent streptococcal infections, a combination of penicillin VK and rifampin
may be used. Rifampicin, 20 mg/kg/d for 4 d, is added to the standard 10d 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 penicillin, but sometimes more acceptable to children because of taste. Some studies suggest that oncedaily dosing of amoxicillin is
adequate therapy for GABHS, but further studies are needed to validate this treatment regimen.
Cephalexin (Keflex)
Firstgeneration 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 oneaday dosing make this a good alternative for patients
who are allergic to penicillin.
Erythromycin (EES, Erythrocin, EryTab)
Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria (eg, M pneumoniae, C
pneumoniae, A haemolyticus), which generally are not sensitive to penicillin. Indicated for patients allergic to penicillin. 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)chlorosubstitution of 7(R)hydroxyl group of parent compound lincomycin. Inhibits bacterial growth, possibly by blocking
dissociation of peptidyl tRNA from ribosomes, causing RNAdependent 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 penicillin 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)
Thirdgeneration cephalosporin with broadspectrum gramnegative activity; lower efficacy against grampositive organisms; higher efficacy against resistant organisms.
Arrests bacterial growth by binding to one or more penicillinbinding proteins. Indicated for cases of gonococcal pharyngitis. Dosing is different for neonatal gonorrhea.
Corticosteroids
Class Summary
Steroids have been shown to improve clinical symptoms in patients with pharyngitis, particularly in patients with severe or exudative pharyngitis.[43] 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.[44, 45] They should be used
selectively for patients with significant swelling or odynophagia.[29, 45]
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 onetime 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.
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 yeastlike 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 (broadspectrum bistriazole) that selectively inhibits fungal CYP450 and sterol C14 alphademethylation.
Followup
Further Outpatient Care
See the list below:
Followup for GAS pharyngitis
A standardized protocol needs to be established at each institution or ED to ensure followup for patients with pending throat cultures. This is particularly
challenging with unreliable patients and with a shiftdependent 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.[1]
A followup culture should be taken if history or evidence of rheumatic fever or if symptoms are consistent with a relapse.[39]
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.[14]
Viral pharyngitis generally requires no specific followup unless immunosuppression is suspected or symptoms worsen.
Patients with suspected malignancy should be referred to an otolaryngologist for followup.
Further Inpatient Care
See the list below:
Inpatient care usually is not indicated except in cases such as epiglottitis, severe dehydration, deepspace infection, other airway compromise, or diphtheria.
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 if a high probability of compromise exists during transfer.
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.[5]
Diphtheria immunization is highly effective and recommended for nonimmunized patients to reduce potential morbidity and mortality of the disease.
Complications
See the list below:
General complications of pharyngitis (mainly seen in cases of bacterial pharyngitis) include sinusitis, otitis media, epiglottitis, 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. It is 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 (35 wk
postinfection), poststreptococcal glomerulonephritis, and toxic shock syndrome.
Complications of infectious mononucleosis include splenic rupture (contact sports should be avoided for 6 wk), hepatitis, GuillainBarré syndrome, encephalitis,
hemolytic anemia, agranulocytosis, myocarditis, Bcell lymphoma, and nasopharyngeal carcinoma. Use of penicillin in cases of infectious mononucleosis results in
near 100% incidence of rash.[14]
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 antibioticrelated or
copathogenic suppression of host immunity and necessary flora.[4] Of note, GAS resistance to penicillin is NOT thought to be a reason for treatment failures with
penicillin.
Patients should expect improvement in symptoms in penicillinsensitive 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 medications and steroid use for pharyngitis are extremely effective for improving symptoms of
pharyngitis.[28]
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 possibility 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.
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 pharyngitis (sore throat)?
What is the role of lab studies in the diagnosis of pharyngitis (sore throat)?
What is the 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) pharyngitis (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 pharyngitis (sore throat)?
What are the main concerns in the emergency department (ED) regarding pharyngitis (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)?
DDX
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 betahemolytic streptococcal (GABHS) rapid antigen detection test in the diagnosis of pharyngitis (sore throat)?
How accurate is the group A betahemolytic streptococcal (GABHS) rapid antigen detection test for the diagnosis of pharyngitis (sore throat)?
What are the benefits of the group A betahemolytic 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)?
Guidelines
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?
Followup
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?
Contributor Information and Disclosures
Author
John R Acerra, MD Assistant Professor, Department of Emergency Medicine, Hofstra North ShoreLIJ School of Medicine; Director, International Emergency Medicine
Fellowship, North ShoreLIJ Health System

John R Acerra, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for
Academic Emergency Medicine

Disclosure: Nothing to disclose.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; EditorinChief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.
Chief Editor
Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor,
Compliance Officer, Department of Emergency Medicine, Palmetto 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 Technology College of Osteopathic Medicine

Jerry R Balentine, DO, 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

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
References
1. Alcaide AL, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2006. 21:449469.
2. Twefik TL, Al Garni M. Tonsillopharyngitis: Clinical highlights. J of Otolaryngology. 2005. 34:
3. Mostov PD. Treating the immunocompetent patient who presents with an upper respiratory infection: pharyngitis, sinusitis, and bronchitis. Prim Care. 2007 Mar. 34(1):3958.
[Medline].
4. Pichichero ME, Casey JR. Systematic review of factors contributing to penicillin treatment failure in Streptococcus pyogenes pharyngitis. Otolaryngol Head Neck Surg. 2007 Dec.
137(6):851857. [Medline].
5. [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 Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary
Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of
Pediatrics. Circulation. 2009 Mar 24. 119(11):154151. [Medline].
6. Centers for Disease Control and Prevention. Summary of notifiable diseases, United States, 1997. MMWR Morb Mortal Wkly Rep. 1998 Nov 20. 46(54):iivii, 387. [Medline].
7. Kalra MG, Higgins KE, Perez ED. Common Questions About Streptococcal Pharyngitis. Am Fam Physician. 2016 Jul 1. 94 (1):2431. [Medline].
8. Shaikh N, Swaminathan N, Hooper EG. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. J Pediatr. 2012 Mar.
160(3):487493.e3. [Medline].
9. Centor RM, Allison JJ, Cohen SJ. Pharyngitis management: defining the controversy. J Gen Intern Med. 2007 Jan. 22(1):12730. [Medline].
10. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G, 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 Nov 15. 55(10):127982. [Medline].
11. Wagner FP, Mathiason MA. Using centor criteria to diagnose streptococcal pharyngitis. Nurse Pract. 2008 Sep. 33(9):102. [Medline].
12. McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ. 2000 Oct 3. 163 (7):8115. [Medline].
13. Fine AM, Nizet V, Mandl KD. Largescale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012 Jun 11. 172 (11):847
52. [Medline]. [Full Text].
14. Gerber MA. Diagnosis and treatment of pharyngitis in children. Pediatr Clin North Am. 2005 Jun. 52(3):72947, vi. [Medline].
15. Lemierre's syndrome, reemergence of a forgotten disease: a case report. Cases J. 2009 Mar 10. 2:6397. [Medline]. [Full Text].
16. Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigendetection test and throat culture in community pediatric offices: implications for
management of pharyngitis. Pediatrics. 2009 Feb. 123(2):43744. [Medline].
17. 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):e0172871. [Medline]. [Full Text].
18. Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev. 2004 Jul. 17 (3):57180, table of contents. [Medline].
19. Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigendetection test and throat culture in community pediatric offices: implications for
management of pharyngitis. Pediatrics. 2009 Feb. 123 (2):43744. [Medline].
20. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2006 Oct 18. CD000023. [Medline].
21. 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 (6):8304. [Medline].
22. Ayanruoh S, Waseem M, Quee F, Humphrey A, Reynolds T. Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department. Pediatr Emerg Care. 2009
Nov. 25(11):74850. [Medline].
23. Pelucchi C, Grigoryan L, Galeone C, Esposito S, Huovinen P, Little P, et al. Guideline for the management of acute sore throat. Clin Microbiol Infect. 2012 Apr. 18 Suppl 1:128.
[Medline].
24. Patel NN, Patel DN. Acute exudative tonsillitis. Am J Med. 2009 Jan. 122(1):1820. [Medline].
25. Cohen JF, Cohen R, Levy C, et al. Selective testing strategies for diagnosing group A streptococcal infection in children with pharyngitis: a systematic review and prospective
multicentre external validation study. CMAJ. 2015 Jan 6. 187(1):2332. [Medline]. [Full Text].
26. Chiappini E, Bortone B, Di Mauro G, et al. Choosing Wisely: The Top5 Recommendations from the Italian Panel of the National Guidelines for the Management of Acute
Pharyngitis in Children. Clin Ther. 2017 Mar. 39 (3):6469. [Medline].
27. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat (Review). The Cochrane Collaboration. 2007. (1):141.
28. Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Corticosteroids as standalone or addon treatment for sore throat. Cochrane Database Syst Rev.
2012 Oct 17. 10:CD008268. [Medline].
29. Tasar A, Yanturali S, Topacoglu H, Ersoy G, Unverir P, Sarikaya S. Clinical efficacy of dexamethasone for acute exudative pharyngitis. J Emerg Med. 2008 Nov. 35(4):3637.
[Medline].
30. Shephard A, Smith G, Aspley S, et al. Randomised, doubleblind, placebocontrolled studies on flurbiprofen 8.75 mg lozenges in patients with/without group A or C streptococcal
throat infection, with an assessment of clinicians' prediction of 'strep throat'. Int J Clin Pract. 2015 Jan. 69(1):5971. [Medline].
31. Muller D, Lindemann T, ShahHosseini K, et al. 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 trial. Eur Arch Otorhinolaryngol. 2016 Apr 28. [Medline].
32. FlemingDutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 20102011. JAMA. 2016 May 3. 315
(17):186473. [Medline].
33. Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 19891999. JAMA. 2001 Sep 12. 286 (10):11816.
[Medline].
34. Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 19972010. JAMA Intern Med. 2014 Jan. 174 (1):13840. [Medline].
35. Matthys J, De Meyere M, van Driel ML, De Sutter A. Differences among international pharyngitis guidelines: not just academic. Ann Fam Med. 2007 SepOct. 5(5):43643.
[Medline].
36. Van Howe RS, Kusnier LP 2nd. Diagnosis and management of pharyngitis in a pediatric population based on costeffectiveness and projected health outcomes. Pediatrics. 2006
Mar. 117(3):60919. [Medline].
37. Pichichero ME. Pathogen shifts and changing cure rates for otitis media and tonsillopharyngitis. Clin Pediatr (Phila). 2006 Jul. 45(6):493502. [Medline].
38. Pichichero M, Casey J. Comparison of European and U.S. results for cephalosporin versus penicillin treatment of group A streptococcal tonsillopharyngitis. Eur J Clin Microbiol
Infect Dis. 2006 Jun. 25(6):35464. [Medline].
39. Brook I. Overcoming penicillin failures in the treatment of Group A streptococcal pharyngotonsillitis. Int J Pediatr Otorhinolaryngol. 2007 Oct. 71(10):15018. [Medline].
40. Logan LK, McAuley JB, Shulman ST. Macrolide treatment failure in streptococcal pharyngitis resulting in acute rheumatic fever. Pediatrics. 2012 Mar. 129(3):e798802. [Medline].
41. Depdham D, Rao S, Hitchcock K. Should you treat carriers of pharyngeal group A strep?. J Fam Pract. 2008. 57:
42. Altamimi S, Khalil A, Khalaiwi KA, Milner 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. [Medline].
43. Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Ann Fam Med. 2010 JanFeb. 8(1):5863. [Medline].
[Full Text].
44. Hayward G, Thompson M, Heneghan C, Perera R, Del Mar C, Glasziou P. Corticosteroids for pain relief in sore throat: systematic review and metaanalysis. BMJ. 2009 Aug 6.
339:b2976. [Medline]. [Full Text].
45. Wing A, VillaRoel C, Yeh B, Eskin B, Buckingham J, Rowe BH. Effectiveness of Corticosteroid Treatment in Acute Pharyngitis: A Systematic Review of the Literature. Acad
Emerg Med. 2010. 17(5):476483.
46. 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
http://www.medscape.com/viewarticle/820008.
47. Huttner B. Antibiotic prescription for sore throat or the legacy of Mr X2.. Lancet Infect Dis. 2014 Jan 16. [Medline].
48. Little P, Stuart B, Hobbs FD, Butler CC, Hay AD, Delaney B, et al. Antibiotic prescription strategies for acute sore throat: a prospective observational cohort study. Lancet Infect
Dis. 2014 Jan 16. [Medline].
49. Nishiyama M, Morioka I, TaniguchiIkeda M, et al. Clinical features predicting group A streptococcal pharyngitis in a Japanese paediatric primary emergency medical centre. J Int
Med Res. 2018 Jan 1. 300060517752954. [Medline]. [Full Text].
50. 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. [Medline].
51. Gottlieb M, Long B, Koyfman A. Clinical Mimics: An Emergency MedicineFocused Review of Streptococcal Pharyngitis Mimics. J Emerg Med. 2018 Mar 6. [Medline].
52. 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):64350. [Medline].

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