tonsillopharyngitis%20-%20acute
TONSILLOPHARYNGITIS - ACUTE
Treatment Guideline Chart
Patients with group A beta-hemolytic streptococcal pharyngitis have classic symptoms of tonsillar swelling/exudates, tender anterior cervical lymphadenopathy, with no cough but with fever of >38ºC.
Clinical features suggestive of a viral etiology are conjunctivitis, absence of fever, coryza, cough, diarrhea, anterior stomatitis, hoarseness, discrete ulcerative lesions, rhinorrhea and viral exanthem and/or enanthem.
Antibiotics will not be needed for every patient that presents with sore throat but it should not be withheld if the clinical condition is severe or group A beta-hemolytic streptococcus is suspected.

Tonsillopharyngitis%20-%20acute Treatment

Principles of Therapy

Antibiotic Therapy

General Therapy Principles

With the exception of very rare infections caused by certain pathogens (Corynebacterium diphtheriae, Neisseria gonorrhoeae), antibiotic therapy is of no proven benefit for acute pharyngitis due to bacteria other than group A beta-hemolytic streptococci (GABS)

  • Viruses are the most common cause of acute pharyngitis and therefore, antibiotics are not warranted in the majority of cases of acute pharyngitis
  • Appropriate antibiotic therapy is needed for GABS because of the following reasons:
    • Prevention of nonsuppurative complications (eg acute rheumatic fever, acute post-streptococcal glomerulonephritis, reactive arthritis)
    • Prevention of suppurative complications (eg peritonsillar abscess, mastoiditis, cervical lymphadenitis)
    • Minimize transmission
    • Shorten the course of illness and allow rapid resumption of patient’s usual activities
  • If there is clinical or epidemiological evidence that results in a high index of suspicion, antimicrobial therapy may be initiated while the physician is waiting for the lab confirmation of GABS pharyngitis
    • Treat GABS infection as soon as possible after diagnosis in high-risk patients to decrease risk of complications and period of contagiousness
  • Empiric antimicrobial therapy for GABS may also be warranted in the following cases:
    • Lack of laboratory access
    • Lack of or unreliable patient follow-up
    • Toxic presentation
  • Group A Streptococci carriers generally do not require treatment and are not likely to infect contacts or have suppurative or nonsuppurative complications
  • If throat culture is the method of diagnosis, discontinue antibiotics if the presumptive diagnosis of GABS pharyngitis is not confirmed by laboratory test results
  • When selecting antimicrobials, consider the following factors:
    • Efficacy and safety
    • Antimicrobial spectrum
    • Dosing schedule
    • Associated compliance with therapy
    • Cost
    • Potential adverse and side effects
  • Antibiotics may be given orally or parenterally, depending on the condition of the patient and compliance concerns

Pharmacotherapy

Symptomatic Therapy

  • Maintain adequate fluid intake
  • Warm salt water
  • Soft foods
  • Warm liquids (eg soup)
  • Throat lozenges/sprays

Antipyretics and Analgesics

  • Patient may take Paracetamol for relief of fever and/or pain
    • Paracetamol is the drug of choice for analgesia in sore throat

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

  • Systemic NSAIDs (eg Ibuprofen, Diclofenac) are safe and effective alternatives for analgesia and antipyrexia
    • Diclofenac may also be used for pain caused by acute tonsillopharyngitis
  • NSAIDs in the form of lozenges and throat sprays are available (eg Flurbiprofen, Benzydamine) 
  • As systemic NSAIDs are associated with significant risk of gastrointestinal bleeding, their routine use is not recommended

Mouth/Throat Preparations

  • May provide symptomatic relief of throat pain 
  • Antiseptic/antibacterial preparations may be used to prevent viral and bacterial infection
  • Further studies are needed to prove the efficacy of mouth/throat preparations in tonsillopharyngitis

Antibiotic Therapy
Indicated only if with high suspicion of or clinically proven GABS infection
Penicillin

  • Drug of choice due to its proven efficacy, safety, low cost, appropriately narrow spectrum of activity and very low rates of resistance of group A beta-hemolytic streptococci to Penicillin

Amoxicillin, Ampicillin, or Amoxicillin/Clavulanic Acid

  • Efficacy appears to be equal to that of Penicillin
  • Spectrum is relatively narrow, cost is also low
  • The suspension form is considerably more palatable than Penicillin V suspension
  • Aminopenicillins should be avoided if mononucleosis is suspected since a macular rash may develop

Cephalosporins

  • First Generation
    • Eg Cefalexin
    • May be used for patients with non-type 1 Penicillin allergy
    • Have a narrow spectrum of activity; much preferred to broad-spectrum cephalosporins
    • Cefadroxil may be used for once-daily therapy of streptococcal pharyngitis
  • Second Generation
    • Eg Cefuroxime
    • May be considered in patients with non-type 1 allergy to Penicillin but generally not recommended because of their broad spectrum of activity
  • Third Generation
    • Eg Cefdinir, Cefixime, Cefpodoxime, Ceftibuten
    • May be considered in patients with non-type 1 allergy to Penicillin but generally not recommended because of their broad spectrum of activity

Macrolides

  • Macrolide resistance may be an issue depending on local resistance patterns
  • Erythromycin
    • Suitable alternative for patients with Penicillin allergy
    • Associated with higher rates of GI effects
    • Estolate salt should not be given to pregnant women due to reported increased risk of cholestatic hepatitis
  • Azithromycin, Clarithromycin, Roxithromycin
    • Offers no microbiologic advantage over Erythromycin, but may be better tolerated
    • Both may be used in patients allergic to penicillins
    • Azithromycin has a higher concentration in pharyngeal tissue

Clindamycin

  • Used in rare patients with Penicillin allergy and an Erythromycin-resistant strain of Streptococcus sp

Duration of Therapy

  • A patient should receive an antimicrobial agent at a dose and for a duration that is likely to eradicate the infecting organism from the pharynx
  • 10 days of antibiotic therapy is recommended to achieve maximal rates of pharyngeal Streptococcus sp eradication
  • Some antibiotics will achieve eradication in <10 days (eg Azithromycin)
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