Pharyngitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chetan Lokhande, M.B.B.S [2], Venkata Sivakrishna Kumar Pulivarthi M.B.B.S [3]

Overview

The majority of cases of pharyngitis are self-limited and only require symptomatic therapy. Accurate diagnosis of streptococcal pharyngitis followed by appropriate antimicrobial therapy is important for the prevention of acute rheumatic fever, for the prevention of suppurative complications (e.g, peritonsillar abscess, cervical lymphadenitis, mastoiditis, and, possibly, other invasive infections), to improve clinical symptoms and signs, for the rapid decrease in contagiousness, for the reduction in transmission of GAS to family members, classmates, and other close contacts of the patient to allow for the rapid resumption of usual activities; and for the minimization of potential adverse effects of inappropriate antimicrobial therapy.[1]

Medical Therapy

  • Acute pharyngitis should be treated according to the etiologic agent.
  • As viral infections are the most common causes of pharyngitis in children, most patients do not require treatment and only need supportive care.[2]
  • Bacterial pharyngitis is common among young children and adolescents. Group A streptococcal pharyngitis is the only common form of the disease for which antimicrobial therapy is definitely indicated. Therefore, when a clinician evaluates a patient with an acute sore throat, the most important clinical task is to decide whether or not the patient has “strep throat.”[3]

Corticosteroids

Corticosteroids have been studied[4] and recommended by a guideline[5], but results were heterogeneous in a meta-analysis[6].

Other Treatment Regimen

Supportive Therapies Systemic Therapy Antimicrobial Regimens

Topical therapy

  • Oral rinses were more effective in treating conditions affecting oral cavity and base of the tongue whereas sprays were more effective in coating the posterior pharynx and hence they were used to treat posterior pharynx conditions.[7]

Oral rinses

  • Salt water gargles do not demonstrate any benefit in relieving throat pain. There are minimal side effects associated with these oral rinses.
  • Lidocaine, Diphenhydramine and Maalox (Aluminium hydroxide, magnesium hydroxide and simethicone) have shown to be helpful. This combination can be used to treat Coxsackie A or B infection or herpes simplex. Avoid using the lidocaine over its recommended use.[8][9]
  • Benzydamine hydrochloride rinses have shown to be help reduce the pain in a few cases. However, they are used more frequently to treat radiation mucositis.[10][11]

Sprays

  • Topical anesthetic sprays have been used in the past to treat pharyngitis, however their effect is not significant. They may also cause a few allergic reactions and side effects, such as methemoglobinemia, and should not be used in children.
  • Chlorhexidine / benzydamine sprays are more effective in alleviating symptoms of acute viral pharyngitis and group A streptococcal pharyngitis.[12][13]

Lozenges

  • Medical throat lozenges help reducing the duration of symptoms and also provide with some symptomatic relief. They are not recommended for children, as there is a risk of choking. Lozenges containing antisepotics, menthol, anesthetics, and anti-inflammatory agents have been used.[3]. Flurbiprofen (trade name Strefen) lozenges may help[14]. Amylmetacresol and 2,4-Dichlorobenzylalcohol (AMC/DCBA) lozenges (trade names Strepsils, Lorsept, and Gorpils) may help[15].

Analgesics

  • Analgesics are prescribed for moderate to severe pain. Acetaminophen, Nonsteroidal anti-inflammatory drugs (NSAIDs) have shown to decrease pain symptoms. They may also help in reducing fever and inflammation.[16][17] Aspirin should be avoided in children as it may cause Reye's syndrome. For severe pain, codeine may be added to the NSAID.

Glucocorticoids

  • Glucocorticoids may alleviate pain, and may also be beneficial in patients of Group A streptococcal pharyngitis. No benefits were obtained by adding single dose glucocorticoid to antimicrobial therapy in children.[18][19][20] Because there are safer and more effective alternatives than glucocorticoids for pain relief associated with fewer side effects, they not recommended for symptomatic relief of throat pain.

Streptococcal pharyngitis[3]

  • Preferred regimen (children): Penicillin V 250 mg PO bid-tid for 10 days
  • Preferred regimen (adolescents and adults): Penicillin V 250 mg PO qid OR 500 mg PO bid for 10 days
  • Alternative regimen (1): Amoxicillin 50 mg/kg PO qd for 10 days (maximum dose 1 g/day) OR 25 mg/kg bid for 10 days (maximum dose 500 mg/day)
  • Alternative regimen (2): Benzathine Penicillin G 0.6 MU (<27 kg)/ 1.2 MU (≥27 kg) IM single dose
  • Alternative regimen (3): Cephalexin 20 mg/kg PO bid for 10 days (maximum 500 mg/dose)
  • Alternative regimen (4): Cefadroxil 30 mg/kg PO qd for 10 days (maximum dose 1 g/day)
  • Alternative regimen (5): Clindamycin 7 mg/kg PO tid for 10 days (maximum 300 mg/dose)
  • Alternative regimen (6): Clarithromycin 7.5 mg/kg PO bid for 10 days (maximum 250 mg/dose)

Other bacterial pharyngitis

Chronic Carriers of Group A Streptococci

Antimicrobial therapy is not indicated for the majority of chronic carriers. A few conditions where antibiotics are recommended are:

  1. An outbreak of rheumatic fever, acute poststreptococcal glomerulonephritis or invasive GAS infection
  2. Closed community outbreak of GAS pharyngitis
  3. Family history of acute rheumatic fever
  4. Excessive anxiety about rheumatic fever

References

  1. Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 55 (10):1279-82. DOI:10.1093/cid/cis847 PMID: 23091044
  2. Bisno AL (1996) Acute pharyngitis: etiology and diagnosis. Pediatrics 97 (6 Pt 2):949-54. PMID: 8637780
  3. 3.0 3.1 3.2 3.3 3.4 Bisno AL (2001) Acute pharyngitis. N Engl J Med 344 (3):205-11. DOI:10.1056/NEJM200101183440308 PMID: 11172144
  4. Hayward GN, Hay AD, Moore MV, Jawad S, Williams N, Voysey M; et al. (2017). "Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial". JAMA. 317 (15): 1535–1543. doi:10.1001/jama.2017.3417. PMC 5470351. PMID 28418482. Review in: Ann Intern Med. 2017 Aug 15;167(4):JC16
  5. Aertgeerts B, Agoritsas T, Siemieniuk RAC, Burgers J, Bekkering GE, Merglen A; et al. (2017). "Corticosteroids for sore throat: a clinical practice guideline". BMJ. 358: j4090. doi:10.1136/bmj.j4090. PMID 28931507. ACPJC review
  6. Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, Papola D, Lytvyn L, Vandvik PO; et al. (2017). "Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials". BMJ. 358: j3887. doi:10.1136/bmj.j3887. PMC 5605780. PMID 28931508.
  7. Patel SK, Ghufoor K, Jayaraj SM, McPartlin DW, Philpott J (1999) Pictorial assessment of the delivery of oropharyngeal rinse versus oropharyngeal spray. J Laryngol Otol 113 (12):1092-4. PMID: 10767923
  8. Hess GP, Walson PD (1988) Seizures secondary to oral viscous lidocaine. Ann Emerg Med 17 (7):725-7. PMID: 3382075
  9. Gonzalez del Rey J, Wason S, Druckenbrod RW (1994) Lidocaine overdose: another preventable case? Pediatr Emerg Care 10 (6):344-6. PMID: 7899121
  10. Turnbull RS (1995) Benzydamine Hydrochloride (Tantum) in the management of oral inflammatory conditions. J Can Dent Assoc 61 (2):127-34. PMID: 7600413
  11. Passàli D, Volonté M, Passàli GC, Damiani V, Bellussi L, MISTRAL Italian Study Group (2001) Efficacy and safety of ketoprofen lysine salt mouthwash versus benzydamine hydrochloride mouthwash in acute pharyngeal inflammation: a randomized, single-blind study. Clin Ther 23 (9):1508-18. PMID: 11589263
  12. Cingi C, Songu M, Ural A, Erdogmus N, Yildirim M, Cakli H et al. (2011) Effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray on clinical signs and quality of life of patients with streptococcal tonsillopharyngitis: multicentre, prospective, randomised, double-blinded, placebo-controlled study. J Laryngol Otol 125 (6):620-5. DOI:10.1017/S0022215111000065 PMID: 21310101
  13. Cingi C, Songu M, Ural A, Yildirim M, Erdogmus N, Bal C (2010) Effects of chlorhexidine/benzydamine mouth spray on pain and quality of life in acute viral pharyngitis: a prospective, randomized, double-blind, placebo-controlled, multicenter study. Ear Nose Throat J 89 (11):546-9. PMID: 21086279
  14. Watson N, Nimmo WS, Christian J, Charlesworth A, Speight J, Miller K (2000) Relief of sore throat with the anti-inflammatory throat lozenge flurbiprofen 8.75 mg: a randomised, double-blind, placebo-controlled study of efficacy and safety. Int J Clin Pract 54 (8):490-6. PMID: 11198725
  15. Weckmann G, Hauptmann-Voß A, Baumeister SE, Klötzer C, Chenot JF (2017). "Efficacy of AMC/DCBA lozenges for sore throat: A systematic review and meta-analysis". Int J Clin Pract. doi:10.1111/ijcp.13002. PMID 28869700.
  16. Thomas M, Del Mar C, Glasziou P (2000) How effective are treatments other than antibiotics for acute sore throat? Br J Gen Pract 50 (459):817-20. PMID: 11127175
  17. Gehanno P, Dreiser RL, Ionescu E, Gold M, Liu JM (2003) Lowest effective single dose of diclofenac for antipyretic and analgesic effects in acute febrile sore throat. Clin Drug Investig 23 (4):263-71. PMID: 17535039
  18. Olympia RP, Khine H, Avner JR (2005) Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children. Arch Pediatr Adolesc Med 159 (3):278-82. DOI:10.1001/archpedi.159.3.278 PMID: 15753273
  19. O'Brien JF, Meade JL, Falk JL (1993) Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med 22 (2):212-5. PMID: 8427434
  20. Bulloch B, Kabani A, Tenenbein M (2003) Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med 41 (5):601-8. DOI:10.1067/mem.2003.136 PMID: 12712025

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