Admit
High risk features for gonacoccal pharyngitis?
Evaluate GAS risk factors:
- 5 - 15 years old
- Late fall to early spring
- Fever >= 38.3 C (101 F)
- Pharyngeal erythema, edema, and/or exudates)
- Tender, enlarged (>1 cm) anterior cervical lymph nodes
Lozenges
- May provide mild, short term relief, but not recommended in children.
Meets discharge criteria?
PO challenge if tolerable level of respiratory distress
High risk features for primary HIV?
Symptoms of a viral URI (conjunctivitis, rhinorrhea, cough, herpangina, etc.)
- Clinical concern for pharyngitis / sore throat
- Toxic appearance
- History of upper airway anatomical or functional abnormality
- Hypotonia or neuromuscular disorder
- Immunosuppressed, cancer
Consider pediatric or ENT consult
Signs of upper airway obstruction?
Consider ENT and/or Anesthesia consults, off pathway
High risk features for gonacoccal pharyngitis
- Oral-genital sex
- Sexual abuse
- Adolescence
Throat sprays
- May provide mild, short term relief, but not recommended in children.
Discharge criteria
- Prescriptions for outpatient meds
- Reassuring vital signs
- Tolerating PO
- Well-appearing
- No social/family concerns
- Reliable follow up in 24 hours
- Patient/Caregivers comfortable and understand discharge plan
- Provider comfortable with outpatient therapy
Contraindications (relative) to probiotics
- Critically ill
- Central venous catheter
- Severely immunocompromised
- Short-bowel syndrome or other altered gut integrity
High risk features for GAS?
> 3 years?
Discharge with follow up with PMD
Probiotics
Contraindications to probiotics?
Systemic analgesics (Acetaminophen / Paracetamol / Ibuprofen)
- Significant decrease in pain scores
Alternative therapies
- Most poorly studied and regulated. Not routinely recommended.
Systemic glucocorticoids
- Not routinely recommended. May be mildly beneficial in severe disease.
Non-GAS bacterial pharyngitis
- Group C and group G streptococcus
- Mycoplasma pneumoniae
- Chlamydophila pneumoniae
- Corynebacterium diphtheriae
- Fusobacterium necrophorum
- Arcanobacterium haemolyticum
High risk features for GAS
- Parent, sibling, child or other household member with recent documented GAS infection
- Known exposure to GAS infected person
- Active local GAS epidemic
- Patient in environment with high risk for transmission (day care worker, health provider)
- Patient with known recurrent GAS infections
Goals of care
- No empiric treatment for group A strep pharyngitis
- Identification of patients at high risk of GAS for testing and treatment
- Identification of patients at risk of pharyngitis complications or disease that may mimic its symptoms
- Adequate, safe pain control and education of patients with and without GAS pharyngitis
Potential beta-lactam therapies
- Penicillin G IM x1
- Penicillin V PO BID x 10 days
- Amoxicillin PO BID x 10 days
Potential therapies if penicillin allergic
- Azithromycin PO Qday x 5 days
- Clindamycin PO TID x 10 days
Potential therapies if reoccurrence
- Penicillin G IM x1
- Clindamycin PO TID x 10 days
Oral rinses / salt water gargles
- May be useful for mouth sores or sore throat
Throat Culture
Should GAS be tested for or treated?
- Controversies and rational for the treatment vs. non-treatment of GAS pharyngitis in the modern developed world.
Systemic analgesia (Acetaminophen/Paracetamol/Ibuprofin)
Potential alternative diagnoses
- Mononucleosis
- Testing is rarely indicated in acute pharyngitis
- Epiglottis
- Submandibular space infections
- Retropharyngeal abscess
- Peritonsillar abscess
- Lemierre syndrome
- Diphtheria
- Consider in patients with travel to endemic areas
- Systemic inflammatory conditions
- Foreign body
- AP & lateral neck x-rays may be useful if suspected
High risk features for primary HIV
- Sexual abuse
- Sexually active adolescents and adults
- Mononucleosis-like symptoms (fever, weight loss, adenopathy, rash, and splenomegaly)
1 or more sign of poor hydration:
- No oral intake
- Minimal urine output
- Clinical signs of severe dehydration
