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Current guidelines of managing pharyngitis
Payal Shah, PA-C
“My throat hurts.” “ It hurts to swallow.” “It feels like razor blades in my throat.” We have all heard different variations of this from our patients. Sore throat, or pharyngitis, is a common complaint seen in the primary care, urgent care and emergency department setting.
Differential Diagnosis
Differentials of sore throat include more commonly strep pharyngitis, viral pharyngitis, COVID-19, tonsillitis, or rarely epiglottitis, peritonsillar abscess, retropharyngeal abscess. The more common ones are usually bacterial or viral sources of the pharyngitis and tonsillitis, and nowadays COVID-19. About 25-45% of pharyngitis have a viral etiology.
When it comes to the complaints of a sore throat, you want to make sure to get a thorough history, perform a physical exam, and document if they’re tolerating PO in the clinic/ED.
Management of pharyngitis
More commonly in terms of managing pharyngitis, you can easily use the Centor criteria, if the patient’s symptoms have been ongoing for less than 3 days. You can also swab the patient for strep and send a throat culture if negative if your facility does that.
One of my facilities does not do strep swabs. We predominantly use Centor criteria and then go based on our clinical judgment. My other facility does strep swabs, and use them frequently along with the Centor criteria.
After using it so often, I am well acquainted with the point system on how to score the patient, but there is also an easy calculator one can use to determine the next steps. I personally use MDCalc but many are available through a google search or in our Clinical Toolkit.
In short, based on their history and exam, you can assign points to determine the next course of
treatment. Using the calculator above can also give you percentages and recommendations.
Use your judgement with a sore throat
Also go based on your clinical judgment. While the chart above states that antibiotics are for positive results only if the patient has a score of 2 or 3, but the patient was inadequately treated for strep recently or has an immunocompromised system, go with your gut to determine if the antibiotics should be empirically given.
Especially now in the setting of COVID-19, pharyngitis is usually managed with supportive and symptomatic care. Combination of acetaminophen, NSAIDs, and viscous lidocaine mouthwash usually helps calm the irritation of the pharyngitis down as well as providing pain control and decreasing the inflammation of the throat.
Management
When Indicated, penicillins are the first choice antibiotic. Oral amoxicillin or Pen VK are suitable options. Cephalosporins, clindamycin or macrolides can also be used In patients with penicillin allergies.
If the tonsils and throat are extremely swollen, prednisone can be given to help with the inflammation. However, you want to keep this as a last resort as adverse effects can occur and usually the infection is managed with analgesics and antibiotics if needed.
If the patient is having difficulty swallowing, cannot tolerate PO, or has voice changes or significant
edema or swelling seen to the oropharynx or neck, keep a low threshold of getting a CT scan to further
assess. For example – I once had a patient, with no significant medical history, who came in with a 1
week history of a sore throat. Had a completely benign physical but almost choked when I gave her
tylenol for her pain (and also as a PO challenge). I ordered a CT that showed a retropharyngeal
abscess. She was admitted with IV antibiotics and had ENT, GI, and thoracic surgery consultants on board.
Back to the Basics
First, assess the patient’s symptoms. Are they drooling or in respiratory distress, have stridor, change in voice, or trismus? Are they febrile? If they are unstable, send them to the ED for proper monitoring and evaluation. If already in the ED, do close re-examinations and start a more thorough workup.
Stable patients need an exam. Consider testing them for COVID-19. Patients who have associated upper respiratory symptoms more likely have a viral etiology and can be treated with supportive care. This decision should be based on your clinical suspicion!
Patients without upper respiratory symptoms, should have centor criteria applied and a strep swab if your clinic/ED does them. If the strep test is positive, treat them accordingly as discussed above. If the initial swab is negative, make sure a throat culture is done. Provide supportive care and inform them of the pending throat culture. Additional testing can be performed with PCR, which tests for any identifiable GAS bacterial fragments. If this test is used, a culture is generally not required due to the high sensitivity and specificity of the test.
The more patients you see with this complaint, the easier this algorithm will be. Like I mentioned before, if their throat examination is benign but they’re just not looking right or not able to tolerate PO, send them to the appropriate department for further testing and evaluation. Stick to your guns! Stick to your clinical gestalt!
References
- Centor RM; Witherspoon JM; Dalton HP; Brody CE; Link K (1981). “The diagnosis of strep throat in adults in the emergency room”. Medical Decision Making. 1 (3): 239–246. doi:10.1177/0272989×8100100304. PMID 6763125. S2CID 23535783.
- McIsaac WJ; Kellner JD; Aufricht P; Vanjaka A; Low DE (7 April 2004). “Empirical Validation of Guidelines for the Management of Pharyngitis in Children and Adults”. Journal of the American Medical Association. 291 (13): 1587–1595. doi:10.1001/jama.291.13.1587. PMID 15069046.
- Marín Cañada J, Cubillo Serna A, Gómez-Escalonilla Cruz N, Garzón de la Iglesia J, Benito Ortiz L, Reyes Fernández MN (July 2007). “Is streptococcal pharyngitis diagnosis possible?”. Aten Primaria (in Spanish). 39 (7): 361–365. doi:10.1157/13107724. PMC 7664574. PMID 17669320.
- Roggen, I; G. van Berlaer; F. Gordts; I. Hubloue (22 April 2013). “Centor Criteria, For what it’s worth”. BMJ Open. 3 (4): e002712. doi:10.1136/bmjopen-2013-002712. PMC 3641432. PMID 23613571.
- “FeverPAIN Score for Strep Pharyngitis”. MDCalc. Retrieved 2021-01-05.
