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SOURCE

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Source: Frei C, Frei B. Upper respiratory tract infections. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=146071422. Accessed March 31, 2017.

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CONDITION/DISORDER SYNONYMS

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  • Strep throat.

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DEFINITION

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  • Infection of oropharynx or nasopharynx.

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ETIOLOGY

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  • Viral causes most common:

    • Rhinovirus.

    • Coronavirus.

    • Adenovirus.

  • Primary bacterial cause: group A β-hemolytic Streptococcus (GABHS) or Streptococcus pyogenes

    • GABHS: 15–30% of cases in pediatric patients and 5–15% in adults.

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PATHOPHYSIOLOGY

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  • Mechanism by which GABHS causes pharyngitis not well defined.

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EPIDEMIOLOGY

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  • Accounts for 2 million emergency department and outpatient visits per year, costing $539 million dollars for children alone.

  • Highest susceptibility: children ages 5–5 years.

  • GABHS:

    • Highest incidence in winter and early spring.

    • Incubation period: 2–5 days.

    • Infectious during acute illness and next 7 days.

      • Effective antibiotic therapy reduces infection period to ~24 hours.

  • Spread occurs via droplet transmission.

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PREVENTION

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  • Diligent handwashing.

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RISK FACTORS

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  • Children who attend school.

  • Parent of school-age child.

  • Working with school-age children.

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CLINICAL PRESENTATION

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  • Most common symptom of pharyngitis: sudden onset of sore throat, mostly self-limited.

  • Symptoms generally resolve in 3–5 days.

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SIGNS AND SYMPTOMS
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  • Similar for viral and nonstreptococcal bacterial causes.

  • Sore throat.

  • Pain on swallowing.

  • Fever.

  • Headache.

  • Nausea.

  • Vomiting.

  • Abdominal pain (especially in children)

  • Erythema/inflammation of tonsils and pharynx with or without patchy exudates.

  • Enlarged, tender lymph nodes.

  • Swollen red uvula.

  • Petechiae on soft palate.

  • Scarlatiniform rash.

  • Signs suggestive of viral origin:

    • Cough.

    • Conjunctivitis.

    • Coryza.

    • Diarrhea.

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DIAGNOSIS

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MEANS OF CONFIRMATION AND DIAGNOSIS
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  • Guidelines from Infectious Disease Society of America, American Academy of Pediatrics, and American Heart Association suggest that testing for group A Streptococcus be done in all patients with signs and symptoms.

  • Centor criteria used to predict GABHS pharyngitis.

    • Recommendation: limit testing to patients who meet ≥2 Centor criteria to minimize overtesting.

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LABORATORY TESTS
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  • Throat swab and culture.

  • Rapid antigen detection testing.

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DIFFERENTIAL DIAGNOSIS
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  • Viral pharyngitis.

  • Epstein-Barr virus (EBV)/infectious mononucleosis.

  • Candidiasis

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DESIRED OUTCOMES

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  • Improve clinical signs and symptoms.

  • Minimize adverse drug reactions.

  • Prevent transmission to close contacts.

  • Prevent acute rheumatic fever.

  • Prevent suppurative complications such as:

    • Peritonsillar abscess.

    • Cervical lymphadenitis.

    • Mastoiditis.

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TREATMENT: GENERAL APPROACH

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  • Antimicrobial treatment should be limited to patients with clinical and epidemiologic features of GABHS pharyngitis with positive laboratory test.

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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • Self-care for pain relief.

    • Acetaminophen: better option because there ...

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