These Guidelines are promulgated by Sentara Health Plan (SHP) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these Guidelines. The SHP Guidelines are institutionally endorsed recommendations and are not intended as a substitute for clinical judgment.

Optima Health

Guidelines for Management of Pharyngitis

Guideline History Original

Approve Date

11/06

Review/Revise Dates

10/06, 09/08, 11/08, 11/10, 01/11, 10/12, 10/14, 11/16, 11/18

Next Review Date

11/20

These Guidelines are promulgated by Sentara Health Plan (SHP) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these Guidelines. The SHP Guidelines are institutionally endorsed recommendations and are not intended as a substitute for clinical judgment.

Guidelines for the Management of Acute Pharyngitis

Acute pharyngitis accounts for 15 million patients seen in U.S. emergency departments and ambulatory care settings annually. Viruses remain the most common cause. Approximately 25 to 30 percent of cases in children and 5 to15 percent of cases in adults are caused by Group A beta-hemolytic streptococcus (GAS). GAS is most common among school-aged children and adolescents of 5-15 years of age.

Patients with sudden onset of sore throat and fever (temperature 100.4o F or higher) and exposure to GAS in the past 2 weeks are most likely to have GAS pharyngitis. Other clinical signs and symptoms include: tonsillopharyngeal inflammation and/or exudates, palatal petechiae, tender anterior cervical nodes, nausea/vomiting and/or abdominal pain and scarlatiniform rash.

Those with nasal congestion and discharge, hoarseness, conjunctivitis, cough, oral ulcers and/or diarrhea are much more consistent with viral pharyngitis. Testing should be avoided for those with such a presentation. GAS carrier state is estimated to have a range of 5-21 percent. Those positive for GAS in the setting of viral symptoms are then much more likely to be unnecessarily exposed to antibiotics.

While GAS pharyngitis is self limited and will resolve within a few days without treatment, acute rheumatic fever (ARF) and pharyngeal abscesses are risks. Antibiotic treatment may lessen the duration of symptoms and is expected to render patients less contagious as well.

GAS is uncommon in children less than 3 years of age as is ARF so testing for GAS should be limited to those with compelling history (fever, mucopurulent rhinitis, adenopathy and older sibling with GAS).

Patients suspected of having GAS pharyngitis should be screened with a rapid antigen detection test (RADT) which is 90-99 percent sensitive. Although this is small risk for a false negative, guidelines recommend children and adolescents have GAS throat culture or DNA amplification/PCR as a backup test. RADT’s and the backup tests do not distinguish GAS pharyngitis from GAS carrier state.

Because adults have a lower risk of both GAS pharyngitis and ARF, backup testing is not recommended.

If testing is positive antimicrobial therapy should be initiated. See the drug list attached to this guideline. Educate the patient (or parent) in the importance of taking the complete course of antibiotic and that they will remain contagious for 24 hours after starting antibiotic. Should improvement not be observed after 48-72 hours of antibiotic treatment their physician should be notified.

If testing is negative educate the patient/family on home symptom management: Acetaminophen or ibuprofen (Do Not advise aspirin for children or teens due to risk for Reye Syndrome) Gargle with warm salt water (1/4 teaspoon of salt per 8 ounces warm water) Older children and adults may suck on throat lozenges, hard candy or ice. Gargling with ice water can be soothing.

Eating soft foods; drink cool or warm beverages; whichever is most soothing Suck on frozen desserts such as popsicles. Apply topical anesthetic to oropharynx only if instructed by physician.

For Patients less than 3 years of age RADT or culture are rarely indicated since acute  Rheumatic fever is rarely a complication of GABHS disease. Test for those with compelling  Symptoms and especially if exposed to a high rate of strep in childcare or household contacts.  

    If positive, treat with one of      the following:   Penicillin V:

< 27 kg: 250mg bid‐tidx 10 days

>27kg: 500mg bid‐tid x10 days

Amoxicillin :

50mg/kg, maximum1000 mg q day x 10days

50mg/kg/day bid ortid x 10 days

IM Penicillin G Benzathine :

<27kg: 600,000 unitsin single dose

>27 kg: 1.2 millionunits in single dose

If Penicillin allergy:

Erythromycin EES40mg/kg/day, bid x 10days

Azithromycin 12mg/kg daily x 5 days

Clarithromycin15mg/kg/day bid x 10days

Clindamycin 20mg/kg/day, max 1.8gm,  tid x 10 days     (for type 1hypersensitivity)

Cephalexin 25‐50mg/kg/day, bid‐tid x10 days

Presents with Sore Throat

RADT 

Pediatric > 3 Years old 

Adults 

Negative RADT 

RADT if two or more of the following symptoms are present: Fever, exudative tonsils, anterior cervical lymph node tenderness or swelling, absence of cough 

Symptomatic Treatment; (Must do throat culture on pediatrics; Physician discretion for adults) 

Positive Throat Culture 

Negative Throat Culture 

For repeated and frequent episodes of acute pharyngitis associated with positive RADT, physician should consider if the patient is a carrier and select patients should be treated. 

If positive, treat with one of the following: 

Penicillin V 500mgbid‐tid x 10 days

Benzathine penicillin1.2 million units IM xone dose

Amoxicillin 250‐500mg tid  x 10 daysor 875mg bid x 10days

If allergy to Penicillin:  

Clindamycin 150mgtid x 10 days (for type1 hypersensitivity)

Cephalexin 500mg bidx 10 days

Erythromycin EES 400mg bid‐qid x 10 days

Azithromycin 500 mgday #1, then, 250mgday #2‐5

Clarithromycin 250‐500mg bid x 10 days

These Guidelines are promulgated by Sentara Health Plan (SHP) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these Guidelines. The SHP Guidelines are institutionally endorsed recommendations and are not intended as a substitute for clinical judgment.

DRUG

Azithromycin

ADVANTAGE

Narrow SpectrumAntibiotic

Good compliance Simple daily dose

schedule

DISADVANTAGE

GI upset Food reduces absorption

from the gastrointestinaltract

Penicillin VK Inexpensive Narrow spectrum of

antimicrobial activity Low side effect profile Bid dosing

Poor taste of liquidpreparations

Penicillin G Benzathine Ensures compliance Pain at injection site Possible increased

incidence of allergies withprocaine

Cannot discontinue drugexposure if serious allergydevelops

Erythromycin Equally effective asPCN in preventing allcomplications ofGABHS

Resistance is uncommonin US (<5%)

RII forms: no differencein cure rate

GI upset

Clarithromycin Acid stable Well absorbed from the

gastrointestinal tract andnot affected by foodconsumption

Headache GI upset

These Guidelines are promulgated by Sentara Health Plan (SHP) as recommendations for the clinical management of specific conditions. Clinical data in a particular case may necessitate or permit deviation from these Guidelines. The SHP Guidelines are institutionally endorsed recommendations and are not intended as a substitute for clinical judgment.

Cephalexin Better cure rate vs oral PCN

Bid dosing Better taste

Broader spectrum

Clindamycin Unaffected by betalactamase

Narrow spectrum Eradicates carrier status

Expensive Pseudomembranous colitis

may occur up to severalweeks after cessation oftherapy

Stevens-Johnsonsyndrome may occur

Poor taste and smell ofliquid preparation

Amoxicillin Taste is preferred overPCN

Found to have treatmentresponse comparative toPCN VK

ANTIBIOTICS AREN’T ALWAYS THE ANSWER.

Antibiotics save lives. Improving the way healthcare

professionals prescribe antibiotics, and the way we

take antibiotics, helps keep us healthy now, helps fight

antibiotic resistance, and ensures that these life-saving

drugs will be available for future generations.

The Facts: When a patient needs antibiotics, the benefits outweigh the risks of side effects or antibiotic resistance.

When antibiotics aren’t needed, they won’t help you, and the side effects could still hurt you.

Common side effects of antibiotics can include rash, dizziness, nausea, diarrhea, or yeast infections. More serious side effects include Clostridium difficile infection (also called C. difficile or C. diff), which causes diarrhea that can lead to severe colon damage and death. People can also have severe and life-threatening allergic reactions.

Antibiotics do not work on viruses, such as colds and flu, or runny noses, even if the mucus is thick, yellow, or green.

Antibiotics are only needed for treating certain infections caused by bacteria. Antibiotics also won’t help for some common bacterial infections including most cases of bronchitis, many sinus infections, and some ear infections.

Taking antibiotics creates resistant bacteria. Antibiotic resistance occurs when bacteria no longer respond to the drugs designed to kill them.

Each year in the United States, at least 2 million people get infected with antibiotic-resistant bacteria. At least 23,000 people die as a result.

If you need antibiotics, take them exactly as prescribed. Talk with your doctor if you have any questions about your antibiotics, or if you develop any side effects, especially diarrhea, since that could be a C. difficile (C. diff) infection which needs to be treated.

Reactions from antibiotics cause

1 out of 5 medication-related visits to

the emergency department. In children,

reactions from antibiotics are the most

common cause of medication-related

emergency department visits.

Questions to Ask Your Healthcare Professional If your child is sick, here are three important questions to ask your healthcare professional:

1. What is the best treatment for my child’s illness?

Your child can feel better without an antibiotic. Respiratory viruses usually go away in a week or two without treatment. Ask your healthcare professional about the best way to feel better while your child’s body fights off the virus.

Common Condition

Common Cause Are Antibiotics Needed?Bacteria

Bacteriaor Virus

Virus

Strep throat Yes

Whooping cough Yes

Urinary tract infection Yes

Sinus infection Maybe

Middle ear infection Maybe

Bronchitis/chest cold (in otherwise healthy children and adults)*

No*

Common cold/runny nose No

Sore throat (except strep) No

Flu No

* Studies show that in otherwise healthy children and adults, antibiotics for bronchitis won’t help you feel better.

2. What do I need to know about the antibiotics you’re prescribing for my child today?

The antibiotic prescribed should be the one most targeted to treat the infection, while causing the least side effects. Some types of antibiotics, such as fluoroquinolones, have a stronger link to severe side effects such as life-threatening C. diff infections. The Food and Drug Administration (FDA) warns healthcare professionals to only prescribe fluoroquinolones when another treatment option is unavailable. These powerful antibiotics are often prescribed even when they are not the recommended treatment.

3. What can I do to help my child feel better?

Pain relievers, fever reducers, saline nasal spray or drops, warm compresses, liquids, and rest may be the best ways to help your child feel better. Your healthcare professional can tell you how to help relieve your child’s symptoms.

To learn more about antibiotic prescribing and use, visit www.cdc.gov/antibiotic-use.

References  

 

1.  Centers for Disease Control and Prevention (CDC) (2018) Antibiotics Aren’t Always the   

   Answer https://www.cdc.gov/antibiotic‐use/community/pdfs/aaw/AU_Arent_Always_The_Answer_fs_508.pdf 

 

2. Centers for Disease Control and Prevention (CDC) (2018) Group A Streptococcal (GAS) 

Disease https://www.cdc.gov/groupastrep/diseases‐hcp/strepthroat.html. 

 

3. Daniel J. Shapiro, Christina E. Lindgren, Mark I. Neuman, Andrew M. Fine: Viral Features 

and Testing for Streptococcal Pharyngitis Pediatrics May 2017, 139 (5) e20163403; DOI: 

10.1542/peds.2016‐3403. 

 

4. David W. Kimberlin, MD, FAAP; Associate Editors: Michael T. Brady, MD, FAAP; Mary Anne     

Jackson, MD, FAAP; and Sarah S. Long, MD, FAAP (Ed.). (n.d.). Red Book®: 2018‐2021 

Report of the Committee on Infectious Diseases.31st.ed. Itasca, IL; American Academy of 

Pediatrics; 2018: 748‐762. 

 

5. Stanford T. Shulman, Alan L. Bisno, Herbert W. Clegg, Michael A. Gerber, Edward L. Kaplan, 

Grace Lee, Judith M. Martin, Chris Van Beneden; Executive Summary: Clinical Practice 

Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 

Update by the Infectious Diseases Society of America, Clinical Infectious Diseases, Volume 

55, Issue 10, 15 November 2012, Pages 1279–1282.