Sore throat resident survival guide

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Sore throat Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, MD[2]

Synonyms and Keywords: An approach to sore throat in adults, Sore throat approach in adults, Approach to pharyngitis in adults, Pharyngitis in adults

Overview

Sore throat, also called as pharyngitis, is a painful sensation in the back part of the throat due to inflammation of the pharynx. It is one of the most frequent complaints among patients visiting their primary care physicians. In the United States, approximately 12 million ambulatory care visits are due to sore throat annually. The majority of cases occur in children and adolescents. The etiology is acute self- limiting viral infection in the majority of individuals. Group A streptococcal infection is the usual causative bacteria for acute pharyngitis in adults. As a physician, it is important to identify clinical signs for life-threatening airway obstruction and deep tissue infection and treat them promptly. This section provides a short and straight to the point overview of the sore throat in adults.

Causes

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of sore throat in adults[10][11][12]:

 
 
 
 
 
 
 
Are there alarming clinical signs for upper airway obstruction or deep neck infection present?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stabilize ABC and refer patient urgently to emergency or inpatient care unit.
Consider the following differential diagnosis:
* Croup
* Acute epiglottitis
 
 
 
 
 
 
 
 
Are clinical signs for viral upper respiratory infection (including conjunctivitis, coryza, cough, viral exanthem and voice hoarseness) present?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manage patient with supportive care.
 
Does patient have clinical features of GAS throat infection?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
Uncertain
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Apply Centor criteria for patient's clinical signs and symptoms. Is score ≥3?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform Rapid antigen detection test (RADT)
 
 
 
 
 
 
 
 
 
 
 
Consider other viral, bacterial or noninfectious causes of sore throat. The illness is mostly self-limiting and specific tests for diagnosis are not carried out.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Positive
 
 
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GAS pharyngitis confirmed - start antibiotics
 
 
 
 
Perform throat culture in patients with any of the following risk factors:
 
 

Treatment

Shown below is an algorithm summarizing the treatment of sore throat in adults according to the Infectious Diseases Society of America guidelines[5][13]:

 
 
 
 
 
 
 
Does patient have strong clinical suspicion for viral URTI?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
 
 
 
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is patient having symptoms suggestive of GAS pharyngitis along with positive RADT?
 
 
 
 
 
 
 
 
Manage patient with supportive care including analgesics, hot fluids, lozenges, and soft diet.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treat patients with empirical antibiotic:

  • Preferred regimen (1): adults: penicillin V 500mg q12h PO for 10 days; children: penicillin V 250mg q12h or q8h PO for 10 days;
  • Preferred regimen (2): amoxicillin 50mg/kg (max: 1gr) qd PO or 25/mg (max: 500mg) bid;
  • Preferred regimen (2): Benzathine G penicillin 1.2mi UI single-dose IM;

If patients are allergic to penicillin:

  • Alternative regimen (1): Cephalexin 20 mg/kg/dose (max: 500mg) bid PO for 10 days
  • Alternative regimen (2): Cefadroxil 30 mg/kg (max: 1gr) qd PO for 10 days
  • Alternative regimen (3): Clindamycin 7 mg/kg/dose (max: 500mg) tid PO for 10 days
  • Alternative regimen (4): Azythromycin 12 mg/kg (max: 500mg) qd PO for 10 days
  • Alternative regimen (5): Clarithromycin 7.5 mg/kg/dose (max: 250mg) bid PO for 10 days
 

Provide supportive care to the patients.

 
 
 
 
 
 

Do's

Don'ts

References

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  2. Bisno AL (2001). "Acute pharyngitis". N Engl J Med. 344 (3): 205–11. doi:10.1056/NEJM200101183440308. PMID 11172144.
  3. Arons MM, Hatfield KM, Reddy SC, Kimball A, James A, Jacobs JR; et al. (2020). "Presymptomatic SARS-CoV-2 Infections and Transmission in a Skilled Nursing Facility". N Engl J Med. 382 (22): 2081–2090. doi:10.1056/NEJMoa2008457. PMC 7200056 Check |pmc= value (help). PMID 32329971 Check |pmid= value (help).
  4. Llor C, Madurell J, Balagué-Corbella M, Gómez M, Cots JM (2011). "Impact on antibiotic prescription of rapid antigen detection testing in acute pharyngitis in adults: a randomised clinical trial". Br J Gen Pract. 61 (586): e244–51. doi:10.3399/bjgp11X572436. PMC 3080229. PMID 21619748.
  5. 5.0 5.1 5.2 5.3 5.4 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.
  6. Centor RM, Atkinson TP, Ratliff AE, Xiao L, Crabb DM, Estrada CA; et al. (2015). "The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study". Ann Intern Med. 162 (4): 241–7. doi:10.7326/M14-1305. PMID 25686164.
  7. Tindall B, Barker S, Donovan B, Barnes T, Roberts J, Kronenberg C; et al. (1988). "Characterization of the acute clinical illness associated with human immunodeficiency virus infection". Arch Intern Med. 148 (4): 945–9. PMID 3258508.
  8. McMillan JA, Weiner LB, Higgins AM, Lamparella VJ (1993). "Pharyngitis associated with herpes simplex virus in college students". Pediatr Infect Dis J. 12 (4): 280–4. doi:10.1097/00006454-199304000-00004. PMID 8387178.
  9. 9.0 9.1 Renner B, Mueller CA, Shephard A (2012). "Environmental and non-infectious factors in the aetiology of pharyngitis (sore throat)". Inflamm Res. 61 (10): 1041–52. doi:10.1007/s00011-012-0540-9. PMC 3439613. PMID 22890476.
  10. Snow V, Mottur-Pilson C, Cooper RJ, Hoffman JR, American Academy of Family Physicians. American College of Physicians-American Society of Internal Medicine; et al. (2001). "Principles of appropriate antibiotic use for acute pharyngitis in adults". Ann Intern Med. 134 (6): 506–8. doi:10.7326/0003-4819-134-6-200103200-00018. PMID 11255529.
  11. Fine AM, Nizet V, Mandl KD (2012). "Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis". Arch Intern Med. 172 (11): 847–52. doi:10.1001/archinternmed.2012.950. PMC 3627733. PMID 22566485.
  12. Webb KH, Needham CA, Kurtz SR (2000). "Use of a high-sensitivity rapid strep test without culture confirmation of negative results: 2 years' experience". J Fam Pract. 49 (1): 34–8. PMID 10678338. Review in: J Fam Pract. 2000 Jul;49(7):660
  13. Harris AM, Hicks LA, Qaseem A, High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention (2016). "Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention". Ann Intern Med. 164 (6): 425–34. doi:10.7326/M15-1840. PMID 26785402.
  14. Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth AL (1997). "Reattendance and complications in a randomized trial of prescribing strategies for sore throat: the medicalizing effect of prescribing antibiotics". BMJ. 315 (7104): 350–2. doi:10.1136/bmj.315.7104.350. PMC 2127265. PMID 9270458.
  15. BRINK WR, RAMMELKAMP CH, DENNY FW, WANNAMAKER LW (1951). "Effect in penicillin and aureomycin on the natural course of streptococcal tonsillitis and pharyngitis". Am J Med. 10 (3): 300–8. doi:10.1016/0002-9343(51)90274-4. PMID 14819035.
  16. Lala I, Leech P, Montgomery L, Bhagat K (2000). "Use of a simple pain model to evaluate analgesic activity of ibuprofen versus paracetamol". East Afr Med J. 77 (9): 504–7. doi:10.4314/eamj.v77i9.46696. PMID 12862143.
  17. Tibballs J, Watson T (2011). "Symptoms and signs differentiating croup and epiglottitis". J Paediatr Child Health. 47 (3): 77–82. doi:10.1111/j.1440-1754.2010.01892.x. PMID 21091577.