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 acute sore throat, the most important clinical task is to decide whether or not the patient has “strep throat.”[3]

Algorithm of Medical therapy for Pharyngitis

Supportive Therapies

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.[4]

Oral rinses
  • Salt water gargles which have been used since a long time have not shown any benefit in releiving throat pain . It is still used as it has minimal side effects.
  • 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.[5][6]
  • 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.[7][8][9][10][11]
Sprays
  • Topical anesthetic sprays have been used in the past to treat pharyngitis , however their effect is not signigficant . They may also cause a few allergic reactions and side effects like methemoglobinemia and hence should not be used in children.
  • Chlorhexidine /benzydamine sprays are more effective in alleviating symptoms of acure viral pharyngitis and group A streptococcal pharyngitis.[12][13]
Lozenges
  • Medical throat lozenges help reducing the duration of symptoms and also provide with some sympotomatic relief. They do come with a few side effects similiar to sprays like methemoglobinemia. They are not recommended for children as there is a risk of choking Lozenges containing antisepotics, menthol , anesthetics and antiflammatory agents have been used.[14][15][16]

Systemic Therapy

Analgesics

Analgesics are prescribed for moderate to severe pain. Acetaminophen , Nonsteroidal antiinflammatory drugs (NSAID) have shown to decrease pain symptoms. They may also help in reducing fever and inflammation.[17][18][19][20][21][22]Aspirin should be avoided in children as it may cause Reye's syndrome .Only for severe pain codeine may be added to the NSAID.

Glucocorticoids

They 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.[23][24][25][26][27][28][29][30]Since there are safer and more effective alternatives than glucocorticoids for pain relief and their long term use come with a few side effects they not recommended for symptomatic relief of throat pain.However in a few conditions like infectious mononucleosis a short term may be help in alleviating pain.

Antibiotic therapy

  • Antibiotics should be used with caution in patients of pharyngitis as all patients do not necessarily need it. They may also cause some undesired complications or side effects. The rationale behind prescribing antibiotics is to prevent complications and secondary infections.[17][31]. They may also allow for rapidly resuming usual activities and prevent spread to family, classmates, and other close contacts.[32]
  • Antibiotics are only needed or prescribed prophylactically for Group A beta-hemolytic streptococci (GAS). Antibiotics may help in decreasing the duration of symptoms but a few studies have shown that analgesic have the a similar or better effect.[17][33]
  • Antibiotics are prescribed for streptococcal pharyngitis to prevent suppurative infections like peritonsillar abscess, cervical lymphadenitis, mastoiditis and other invasive infections and non-suppurative complications like acute rheumatic fever
  • Of note, poststreptococcal glomerulonephritis is not prevented by antibiotic therapy.
  • Inappropriate or overzealous use of antibiotics for treatment of pharyngitis is one of the major causes of antibiotic resistance.[34][35][36]
Antimicrobial Regimens
  • 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
    • Arcanobacterium haemolyticum: Erythromycin is the preferred drug.[3]
    • Neisseria gonorrhoeae: If uncomplicated[3]
      • single dose of intramuscular ceftriaxone (125 mg) or a single dose of an oral quinolone (ciprofloxacin, 500 mg, or ofloxacin, 400 mg) +
      • single dose of azithromycin (1 g) or doxycycline (100 mg) twice daily for seven days for possible chlamydial coinfection at genital sites.
      • Doxycycline and ofloxacin should not be prescribed for pregnant women.

Chronic Carriers of Group A Streptococci

Antimicrobial therapy is not indicated for 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
  5. If tonsillectomy in considered because of carriage.

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. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 3.2 3.3 Bisno AL (2001) Acute pharyngitis. N Engl J Med 344 (3):205-11. DOI:10.1056/NEJM200101183440308 PMID: 11172144
  4. ↑ 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. Unknown parameter |month= ignored (help)
  5. ↑ Hess, GP.; Walson, PD. (1988). "Seizures secondary to oral viscous lidocaine". Ann Emerg Med. 17 (7): 725–7. PMID 3382075. Unknown parameter |month= ignored (help)
  6. ↑ Gonzalez del Rey, J.; Wason, S.; Druckenbrod, RW. (1994). "Lidocaine overdose: another preventable case?". Pediatr Emerg Care. 10 (6): 344–6. PMID 7899121. Unknown parameter |month= ignored (help)
  7. ↑ Turnbull, RS. (1995). "Benzydamine Hydrochloride (Tantum) in the management of oral inflammatory conditions". J Can Dent Assoc. 61 (2): 127–34. PMID 7600413. Unknown parameter |month= ignored (help)
  8. ↑ Passàli, D.; Volonté, M.; Passàli, GC.; Damiani, V.; Bellussi, L. (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. Unknown parameter |month= ignored (help)
  9. ↑ Wethington, JF. (1985). "Double-blind study of benzydamine hydrochloride, a new treatment for sore throat". Clin Ther. 7 (5): 641–6. PMID 3902241.
  10. ↑ Epstein, JB.; Silverman, S.; Paggiarino, DA.; Crockett, S.; Schubert, MM.; Senzer, NN.; Lockhart, PB.; Gallagher, MJ.; Peterson, DE. (2001). "Benzydamine HCl for prophylaxis of radiation-induced oral mucositis: results from a multicenter, randomized, double-blind, placebo-controlled clinical trial". Cancer. 92 (4): 875–85. PMID 11550161. Unknown parameter |month= ignored (help)
  11. ↑ Kim, JH.; Chu, FC.; Lakshmi, V.; Houde, R. (1986). "Benzydamine HCl, a new agent for the treatment of radiation mucositis of the oropharynx". Am J Clin Oncol. 9 (2): 132–4. PMID 3521255. Unknown parameter |month= ignored (help)
  12. ↑ Cingi, C.; Songu, M.; Ural, A.; Erdogmus, N.; Yildirim, M.; Cakli, H.; Bal, C. (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. Unknown parameter |month= ignored (help)
  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. Unknown parameter |month= ignored (help)
  14. ↑ Bisno, AL. (2001). "Acute pharyngitis". N Engl J Med. 344 (3): 205–11. doi:10.1056/NEJM200101183440308. PMID 11172144. Unknown parameter |month= ignored (help)
  15. ↑ 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. Unknown parameter |month= ignored (help)
  16. ↑ "Flurbiprofen: new indication. Lozenges: NSAIDs are not to be taken like sweets!". Prescrire Int. 16 (87): 13. 2007. PMID 17323518. Unknown parameter |month= ignored (help)
  17. ↑ 17.0 17.1 17.2 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. Unknown parameter |month= ignored (help)
  18. ↑ 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.
  19. ↑ Schachtel, BP.; Thoden, WR. (1993). "A placebo-controlled model for assaying systemic analgesics in children". Clin Pharmacol Ther. 53 (5): 593–601. PMID 8491069. Unknown parameter |month= ignored (help)
  20. ↑ Bertin, L.; Pons, G.; d'Athis, P.; Lasfargues, G.; Maudelonde, C.; Duhamel, JF.; Olive, G. (1991). "Randomized, double-blind, multicenter, controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children". J Pediatr. 119 (5): 811–4. PMID 1941391. Unknown parameter |month= ignored (help)
  21. ↑ Benarrosh, C. "[Multicenter double blind study of tiaprofenic acid versus placebo in tonsillitis and pharyngitis in children]". Arch Fr Pediatr. 46 (7): 541–6. PMID 2688592.
  22. ↑ Eccles, R.; Loose, I.; Jawad, M.; Nyman, L. (2003). "Effects of acetylsalicylic acid on sore throat pain and other pain symptoms associated with acute upper respiratory tract infection". Pain Med. 4 (2): 118–24. PMID 12873261. Unknown parameter |month= ignored (help)
  23. ↑ 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. Unknown parameter |month= ignored (help)
  24. ↑ 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. Unknown parameter |month= ignored (help)
  25. ↑ 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. Unknown parameter |month= ignored (help)
  26. ↑ Marvez-Valls, EG.; Stuckey, A.; Ernst, AA. (2002). "A randomized clinical trial of oral versus intramuscular delivery of steroids in acute exudative pharyngitis". Acad Emerg Med. 9 (1): 9–14. PMID 11772663. Unknown parameter |month= ignored (help)
  27. ↑ Roy, M.; Bailey, B.; Amre, DK.; Girodias, JB.; Bussières, JF.; Gaudreault, P. (2004). "Dexamethasone for the treatment of sore throat in children with suspected infectious mononucleosis: a randomized, double-blind, placebo-controlled, clinical trial". Arch Pediatr Adolesc Med. 158 (3): 250–4. doi:10.1001/archpedi.158.3.250. PMID 14993084. Unknown parameter |month= ignored (help)
  28. ↑ Niland, ML.; Bonsu, BK.; Nuss, KE.; Goodman, DG. (2006). "A pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis". Pediatr Infect Dis J. 25 (6): 477–81. doi:10.1097/01.inf.0000219469.95772.3f. PMID 16732143. Unknown parameter |month= ignored (help)
  29. ↑ Wing, A.; Villa-Roel, C.; Yeh, B.; Eskin, B.; Buckingham, J.; Rowe, BH. (2010). "Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature". Acad Emerg Med. 17 (5): 476–83. doi:10.1111/j.1553-2712.2010.00723.x. PMID 20536799. Unknown parameter |month= ignored (help)
  30. ↑ Hayward, G.; Thompson, MJ.; Perera, R.; Glasziou, PP.; Del Mar, CB.; Heneghan, CJ. (2012). "Corticosteroids as standalone or add-on treatment for sore throat". Cochrane Database Syst Rev. 10: CD008268. doi:10.1002/14651858.CD008268.pub2. PMID 23076943.
  31. ↑ Spinks, A.; Glasziou, PP.; Del Mar, CB. (2013). "Antibiotics for sore throat". Cochrane Database Syst Rev. 11: CD000023. doi:10.1002/14651858.CD000023.pub4. PMID 24190439.
  32. ↑ Lindbaek, M.; Francis, N.; Cannings-John, R.; Butler, CC.; Hjortdahl, P. (2006). "Clinical course of suspected viral sore throat in young adults: cohort study". Scand J Prim Health Care. 24 (2): 93–7. doi:10.1080/02813430600638227. PMID 16690557. Unknown parameter |month= ignored (help)
  33. ↑ Bradley, CP. (2000). "Taking another look at the acute sore throat". Br J Gen Pract. 50 (459): 780–1. PMID 11127165. Unknown parameter |month= ignored (help)
  34. ↑ Linder, JA.; Bates, DW.; Lee, GM.; Finkelstein, JA. (2005). "Antibiotic treatment of children with sore throat". JAMA. 294 (18): 2315–22. doi:10.1001/jama.294.18.2315. PMID 16278359. Unknown parameter |month= ignored (help)
  35. ↑ Linder, JA.; Chan, JC.; Bates, DW. (2006). "Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic". Arch Intern Med. 166 (13): 1374–9. doi:10.1001/archinte.166.13.1374. PMID 16832002. Unknown parameter |month= ignored (help)
  36. ↑ McCaig, LF.; Besser, RE.; Hughes, JM. (2002). "Trends in antimicrobial prescribing rates for children and adolescents". JAMA. 287 (23): 3096–102. PMID 12069672. Unknown parameter |month= ignored (help)
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