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Source: Frei C, Frei B, Zhanel G. Upper Respiratory Tract Infections. In: DiPiro, JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. Accessed July 15, 2012.

  • Strep throat

  • Infection of oropharynx or nasopharynx

  • 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

  • Mechanism by which GABHS causes pharyngitis not well defined.
  • 5–20% of children GABHS carriers.

  • 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.

  • Diligent handwashing

  • Children who attend school
  • Parent of school-age child
  • Working with school-age children

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

Signs and Symptoms

  • 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:

Means of Confirmation and Diagnosis

  • 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.

Laboratory Tests

  • Throat swab and culture
  • Rapid antigen detection testing

Differential Diagnosis

  • Viral pharyngitis
  • Epstein-Barr virus (EBV)/infectious mononucleosis
  • Candidiasis

  • 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

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

  • Self-care for pain relief
    • Acetaminophen: better option because there is some concern that NSAIDs may increase risk for necrotizing fasciitis or toxic shock syndrome.
    • NSAIDs
    • Nonprescription lozenges and sprays containing menthol and topical anesthetics
    • Salt-water gargling

  • Penicillin drug of choice in treatment of GABHS pharyngitis (Table 1).
    • Treat for 10 days to maximize bacterial eradication.
    • If allergic to penicillin, macrolide such as erythromycin or first-generation cephalosporin such as cephalexin (if reaction is non-immunoglobulin E–mediated hypersensitivity) can be used.
  • Dosing guidelines for recurrent infections varies slightly.
  • Table 2 presents evidence-based principles for diagnosis of group A Streptococcus pharyngitis.

Table 1. Dosing Guidelines for Pharyngitis

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