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Canadian Family Physician Medecin de... Apr 2020To provide family physicians with an updated approach to diagnosis and treatment of pharyngitis, detailing key symptoms, methods of investigation, and a summary of... (Review)
Review
OBJECTIVE
To provide family physicians with an updated approach to diagnosis and treatment of pharyngitis, detailing key symptoms, methods of investigation, and a summary of common causes.
SOURCES OF INFORMATION
The approach described is based on the authors' clinical practice and peer-reviewed literature from 1989 to 2018.
MAIN MESSAGE
Sore throat caused by pharyngitis is commonly seen in family medicine clinics and is caused by inflammation of the pharynx and surrounding tissues. Pharyngitis can be caused by viral, bacterial, or fungal infections. Viral causes are often self-limiting, while bacterial and fungal infections typically require antimicrobial therapy. Rapid antigen detection tests and throat cultures can be used with clinical findings to identify the inciting organism. Pharyngitis caused by is among the most concerning owing to its associated severe complications such as acute rheumatic fever and glomerulonephritis. Hence, careful diagnosis of pharyngitis is necessary to provide targeted treatment.
CONCLUSION
A thorough history is key to diagnosing pharyngitis. Rapid antigen detection tests should be reserved for concerns about antibiotic initiation. Physicians should exercise restraint in antibiotic initiation for pharyngitis, as restraint does not delay recovery or increase the risk of infections.
Topics: Anti-Bacterial Agents; Humans; Pharyngitis; Rheumatic Fever; Streptococcal Infections; Streptococcus pyogenes
PubMed: 32273409
DOI: No ID Found -
Frontiers in Cellular and Infection... 2020The most common bacterial cause of pharyngitis is infection by Group A -hemolytic streptococcus (GABHS), commonly known as strep throat. 5-15% of adults and 15-35% of... (Review)
Review
The most common bacterial cause of pharyngitis is infection by Group A -hemolytic streptococcus (GABHS), commonly known as strep throat. 5-15% of adults and 15-35% of children in the United States with pharyngitis have a GABHS infection. The symptoms of GABHS overlap with non-GABHS and viral causes of acute pharyngitis, complicating the problem of diagnosis. A careful physical examination and patient history is the starting point for diagnosing GABHS. After a physical examination and patient history is completed, five types of diagnostic methods can be used to ascertain the presence of a GABHS infection: clinical scoring systems, rapid antigen detection tests, throat culture, nucleic acid amplification tests, and machine learning and artificial intelligence. Clinical guidelines developed by professional associations can help medical professionals choose among available techniques to diagnose strep throat. However, guidelines for diagnosing GABHS created by the American and European professional associations vary significantly, and there is substantial evidence that most physicians do not follow any published guidelines. Treatment for GABHS using analgesics, antipyretics, and antibiotics seeks to provide symptom relief, shorten the duration of illness, prevent nonsuppurative and suppurative complications, and decrease the risk of contagion, while minimizing the unnecessary use of antibiotics. There is broad agreement that antibiotics with narrow spectrums of activity are appropriate for treating strep throat. But whether and when patients should be treated with antibiotics for GABHS remains a controversial question. There is no clearly superior management strategy for strep throat, as significant controversy exists regarding the best methods to diagnose GABHS and under what conditions antibiotics should be prescribed.
Topics: Adult; Anti-Bacterial Agents; Artificial Intelligence; Child; Humans; Pharyngitis; Streptococcal Infections; Streptococcus pyogenes; United States
PubMed: 33178623
DOI: 10.3389/fcimb.2020.563627 -
Deutsches Arzteblatt International Mar 2021Sore throat is a common reason for consultation of primary care physicians, pediatricians, and ENT specialists. The updated German clinical practice guideline on sore...
BACKGROUND
Sore throat is a common reason for consultation of primary care physicians, pediatricians, and ENT specialists. The updated German clinical practice guideline on sore throat provides evidence-based recommendations for treatment in the German healthcare system.
METHODS
Guideline revision by means of a systematic search of the literature for international guidelines and systematic reviews. All recommendations resulted from interdisciplinary cooperation and were agreed by formal consensus. The updated guideline applies to patients aged 3 years and over.
RESULTS
In the absence of red flags such as immunosuppression, severe comorbidity, or severe systemic infection, acute sore throat is predominantly self-limiting. The mean duration is 7 days. Chronic sore throat usually has noninfectious causes. Laboratory tests are not routinely necessary. Apart from non-pharmacological self-management, ibuprofen and naproxen are recommended for symptomatic treatment. Scores can be used to assess the risk of bacterial pharyngitis: one point each is assigned for tonsil lesions, palpable cervical lymph nodes, patient age, disease course, and elevated temperature. If the risk is low (<3 points), antibiotics are not indicated; if at least moderate (3 points), delayed prescribing is recommended; if high (>3 points), antibiotics can be taken immediately. Penicillin remains the first choice, with clarithromycin as an alternative for those who do not tolerate penicillin. The antibiotic should be taken for 5-7 days.
CONCLUSION
After the exclusion of red flags, antibiotic treatment is unnecessary in many cases of acute sore throat. If administration of antibiotics is still considered in spite of consultation on the usual course of tonsillopharyngitis and the low risk of complications, a risk-adapted approach using clinical scores is recommended.
Topics: Anti-Bacterial Agents; Fever; Humans; Pain; Penicillins; Pharyngitis
PubMed: 33602392
DOI: 10.3238/arztebl.m2021.0121 -
American Family Physician Jan 2023Tonsillitis, or inflammation of the tonsils, makes up approximately 0.4% of outpatient visits in the United States. Tonsillitis is caused by a viral infection in 70% to...
Tonsillitis, or inflammation of the tonsils, makes up approximately 0.4% of outpatient visits in the United States. Tonsillitis is caused by a viral infection in 70% to 95% of cases. However, bacterial infections caused by group A beta-hemolytic streptococcus (Streptococcus pyogenes) account for tonsillitis in 5% to 15% of adults and 15% to 30% of patients five to 15 years of age. It is important to differentiate group A beta-hemolytic streptococcus from other bacterial or viral causes of pharyngitis and tonsillitis because of the risk of progression to more systemic complications such as abscess, acute glomerulonephritis, rheumatic fever, and scarlet fever after infection with group A beta-hemolytic streptococcus. A variety of diagnostic tools are available, including symptom-based validated scoring systems (e.g., Centor score), and oropharyngeal and serum laboratory testing. Treatment is focused on supportive care, and if group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic. In cases of recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years. Tonsilloliths, or tonsil stones, are managed expectantly, and small tonsilloliths are common clinical findings. Rarely, surgical intervention is required if they become too large to pass on their own.
Topics: Adult; Humans; Tonsillitis; Pharyngitis; Streptococcus pyogenes; Anti-Bacterial Agents; Abscess; Streptococcal Infections
PubMed: 36689967
DOI: No ID Found -
European Journal of Pediatrics Dec 2023This study aims to provide a comparison of the current recommendations about the management of acute pharyngitis. A literature search was conducted from January 2009 to... (Review)
Review
This study aims to provide a comparison of the current recommendations about the management of acute pharyngitis. A literature search was conducted from January 2009 to 2023. Documents reporting recommendations on the management of acute pharyngitis were included, pertinent data were extracted, and a descriptive comparison of the different recommendations was performed. The quality of guidelines was assessed through the AGREE II instrument. Nineteen guidelines were included, and an overall moderate quality was found. Three groups can be distinguished: one group supports the antibiotic treatment of group A β-hemolytic Streptococcus (GABHS) to prevent acute rheumatic fever (ARF); the second considers acute pharyngitis a self-resolving disease, recommending antibiotics only in selected cases; the third group recognizes a different strategy according to the ARF risk in each patient. An antibiotic course of 10 days is recommended if the prevention of ARF is the primary goal; conversely, some guidelines suggest a course of 5-7 days, assuming the symptomatic cure is the goal of treatment. Penicillin V and amoxicillin are the first-line options. In the case of penicillin allergy, first-generation cephalosporins are a suitable choice. In the case of beta-lactam allergy, clindamycin or macrolides could be considered according to local resistance rates. Conclusion: Several divergencies in the management of acute pharyngitis were raised among guidelines (GLs) from different countries, both in the diagnostic and therapeutic approach, allowing the distinction of 3 different strategies. Since GABHS pharyngitis could affect the global burden of GABHS disease, it is advisable to define a shared strategy worldwide. It could be interesting to investigate the following issues further: cost-effectiveness analysis of diagnostic strategies in different healthcare systems; local genomic epidemiology of GABHS infection and its complications; the impact of antibiotic treatment of GABHS pharyngitis on its complications and invasive GABHS infections; the role of GABHS vaccines as a prophylactic measure. The related results could aid the development of future recommendations. What is Known: • GABHS disease spectrum ranges from superficial to invasive infections and toxin-mediated diseases. • GABHS accounts for about 25% of sore throat in children and its management is a matter of debate. What is New: • Three strategies can be distinguished among current GLs: antibiotic therapy to prevent ARF, antibiotics only in complicated cases, and a tailored strategy according to the individual ARF risk. • The impact of antibiotic treatment of GABHS pharyngitis on its sequelae still is the main point of divergence; further studies are needed to achieve a global shared strategy.
Topics: Child; Adult; Humans; Streptococcus pyogenes; Streptococcal Infections; Pharyngitis; Anti-Bacterial Agents; Hypersensitivity
PubMed: 37819417
DOI: 10.1007/s00431-023-05211-w -
Pediatric Annals Sep 2019For pediatric practitioners, acute otitis media (AOM) and group A streptococcal pharyngitis are two of the most common infections seen in ambulatory practices. The... (Review)
Review
For pediatric practitioners, acute otitis media (AOM) and group A streptococcal pharyngitis are two of the most common infections seen in ambulatory practices. The purpose of this article is to review these conditions with the focus of highlighting evidence-based guidelines. AOM in children is a visual diagnosis and not one that can be made on history alone. The American Academy of Pediatrics (AAP) guidelines have clear criteria to aid clinicians in how to diagnose AOM. The pneumatic otoscope is the standard tool used to diagnose otitis media, and the AAP guidelines stress developing proficiency in distinguishing a normal tympanic membrane from otitis media with effusion or AOM. There are several components to appropriate management (treatment) of AOM including analgesia, education, antibiotics, and the option (for some) for observation. Group A streptococcal pharyngitis is the most common bacterial cause of sore throat in children but still only accounts for a minority of cases. History and physical examination help determine who should be tested. Testing is required to determine who to treat. Up to 15% of children in the United States are carriers, so indiscriminate testing can lead to inappropriate antibiotic use. If a patient's test is positive, treatment is recommended and penicillin or amoxicillin are appropriate for most cases. [Pediatr Ann. 2019;48(9):e343-e348.].
Topics: Acute Disease; Adolescent; Child; Child, Preschool; Evidence-Based Medicine; General Practice; Humans; Infant; Otitis Media; Pediatrics; Pharyngitis; Practice Guidelines as Topic; Streptococcal Infections; Streptococcus pyogenes
PubMed: 31505007
DOI: 10.3928/19382359-20190813-01 -
Pediatric Rheumatology Online Journal Apr 2020Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. There is considerable...
Consensus treatment plans for periodic fever, aphthous stomatitis, pharyngitis and adenitis syndrome (PFAPA): a framework to evaluate treatment responses from the childhood arthritis and rheumatology research alliance (CARRA) PFAPA work group.
BACKGROUND
Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. There is considerable heterogeneity in management strategies and a lack of evidence-based treatment guidelines. Consensus treatment plans (CTPs) are standardized treatment regimens that are derived based upon best available evidence and current treatment practices that are a way to enable comparative effectiveness studies to identify optimal therapy and are less costly to execute than randomized, double blind placebo controlled trials. The purpose of this project was to develop CTPs and response criteria for PFAPA.
METHODS
The CARRA PFAPA Working Group is composed of pediatric rheumatologists, infectious disease specialists, allergists/immunologists and otolaryngologists. An extensive literature review was conducted followed by a survey to assess physician practice patterns. This was followed by virtual and in-person meetings between 2014 and 2018. Nominal group technique (NGT) was employed to develop CTPs, as well as inclusion criteria for entry into future treatment studies, and response criteria. Consensus required 80% agreement.
RESULTS
The PFAPA working group developed CTPs resulting in 4 different treatment arms: 1. Antipyretic, 2. Abortive (corticosteroids), 3. Prophylaxis (colchicine or cimetidine) and 4. Surgical (tonsillectomy). Consensus was obtained among CARRA members for those defining patient characteristics who qualify for participation in the CTP PFAPA study.
CONCLUSION
The goal is for the CTPs developed by our group to lead to future comparative effectiveness studies that will generate evidence-driven therapeutic guidelines for this periodic inflammatory disease.
Topics: Adrenal Cortex Hormones; Advisory Committees; Antipyretics; Child; Child, Preschool; Cimetidine; Colchicine; Fever; Histamine H2 Antagonists; Humans; Lymphadenitis; Neck; Pharyngitis; Stomatitis, Aphthous; Syndrome; Tonsillectomy; Tubulin Modulators
PubMed: 32293478
DOI: 10.1186/s12969-020-00424-x -
Kyobu Geka. the Japanese Journal of... Sep 2022Acute mediastinitis is a deep thoracic infection. In particular, descending necrotizing mediastinitis (DNM) is serious and potentially fatal, however, the initial...
Acute mediastinitis is a deep thoracic infection. In particular, descending necrotizing mediastinitis (DNM) is serious and potentially fatal, however, the initial symptoms are often not severe. It is caused by prolonged oropharyngeal or odontogenic infections such as pharyngitis, tonsillitis, and dental caries. The most common pathogens are Gram-positive cocci and anaerobes, and patients often have underlying medical conditions such as diabetes mellitus, steroid use, and chronic renal failure. Surgical drainage is necessary for treatment, and surgery should be performed as soon as possible after diagnosis. The mortality rate of DNM was initially reported to be more than 40%, but has improved to less than 20% in recent years. Proper judgment and appropriate surgery have contributed to the improvement of the life-saving rate.
Topics: Acute Disease; Dental Caries; Drainage; Humans; Mediastinitis; Necrosis; Pharyngitis; Steroids
PubMed: 36155583
DOI: No ID Found -
Infectious Diseases Now Nov 2023Ear, nose and throat (ENT) or upper respiratory tract infections (URTI) are the most common infections in children and the leading causes of antibiotic prescriptions. In... (Review)
Review
Ear, nose and throat (ENT) or upper respiratory tract infections (URTI) are the most common infections in children and the leading causes of antibiotic prescriptions. In most cases, these infections are due to (or are triggered by) viruses and even when bacterial species are implicated, recovery is usually spontaneous. The first imperative is to refrain from prescribing antibiotics in a large number of URTIs: common cold, most cases of sore throat, laryngitis, congestive otitis, and otitis media with effusion. On the contrary, a decision to treat sore throats with antibiotics is based primarily on the positivity of the Group A Streptococcus (GAS) rapid antigen diagnostic tests. For ear infections, only (a) purulent acute otitis media in children under 2 years of age and (b) complicated or symptomatic forms of purulent acute otitis media (PAOM) in older children should be treated with antibiotics. Amoxicillin is the first-line treatment in the most cases of ambulatory ENT justifying antibiotics. Severe ENT infections (mastoiditis, epiglottitis, retro- and parapharyngeal abscesses, ethmoiditis) are therapeutic emergencies necessitating hospitalization and initial intravenous antibiotic therapy.
Topics: Child; Humans; Infant; Anti-Infective Agents; Pharyngitis; Respiratory Tract Infections; Anti-Bacterial Agents; Otitis Media
PubMed: 37730165
DOI: 10.1016/j.idnow.2023.104785 -
JAAPA : Official Journal of the... Oct 2023Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is, as the name implies, characterized by an extremely regular cycle of fevers that is...
Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is, as the name implies, characterized by an extremely regular cycle of fevers that is accompanied by one or more other symptoms such as oral ulcers, pharyngitis, adenitis, tonsillitis, sore throat, cervical adenopathy, and headache. Originally known as Marshall syndrome, PFAPA is most commonly identified in children younger than age 5 years; however, adults may also present with the disease, though they may report additional symptoms. PFAPA is now understood to be a diagnosis of exclusion. Laboratory studies are typically unremarkable except for increases in acute phase reactants such as C-reactive protein. Treatment is primarily supportive and most frequently uses systemic steroids to suppress the inflammatory response. Acute flares are self-limited, and the syndrome typically resolves on its own as the child reaches age 7 or 8 years.
Topics: Adult; Child; Humans; Child, Preschool; Stomatitis, Aphthous; Lymphadenopathy; Lymphadenitis; Pharyngitis; Syndrome; Fever
PubMed: 37751263
DOI: 10.1097/01.JAA.0000977712.81696.b9