Acute Pharyngitis and Sore Throat

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Acute Pharyngitis and Sore Throat


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


  • May provide mild, short term relief, but not recommended in children.

Strep Throat Screen Rapid

Meets discharge criteria?

PO challenge if tolerable level of respiratory distress

PO Challenge

High risk features for primary HIV?

HIV Antigen/Antibody Rapid, Serum

Symptoms of a viral URI (conjunctivitis, rhinorrhea, cough, herpangina, etc.)

Inclusion Criteria
  • Clinical concern for pharyngitis / sore throat
Exclusion Criteria
  • 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


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

NS Bolus
NS infusion

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

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