Health Care Guideline:
Acute Pharyngitis
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Leader
William Rabe, MD, Allina Medical Group North
Family Practice
Margaret Gill, MD, Mayo Clinic
Ken Olson, MD, HealthSystem Minnesota
Internal Medicine
James Hart, MD, HealthPartners
Laboratory
Linda Johnson, BSMT, HealthPartners
Nursing
Julie White, RN, HealthPartners
Pediatrics
William Rabe, MD, Allina Medical Group North
Leonard Snellman, MD, HealthPartners
Health Education
Debra Boal, RN, ICCE, HealthSystem Minnesota
Measurement Advisor
Jane Gendron, ICSI
Buyers Health Care Action Group Representative
Laurie Fenwick, Minnesota Mutual
Facilitator
Jane McNamara, RN, BSN, Interstate Medical Center
The ICSI acute pharyngitis guideline addresses primary care evaluation and management of acute pharyngitis in patients 3 years of age or older.
Priority Aims for Medical Groups When Using This Guideline
1. Reduce testing of patients for GABS who present with concomitant VURI symptoms.
Possible measures of accomplishing this aim:
a. Percentage of patients tested with Rapid Strep Test (RST) or Strep Throat Culture (STCX) with VURI symptoms.
2. Reduce excessive antibiotic treatment through decreased empiric treatment.
Possible measures of accomplishing this aim:
a. Percentage of patients treated with antibiotics who had a negative culture or no RST or STCX.
3. Increase the use of recommended first-line medications.
Possible measures of accomplishing this aim:
a. Percentage of patients treated with penicillin, erythromycin, or cephalexin.
4. Increase patient knowledge about pharyngitis and pharyngitis care.
Possible measures of accomplishing this aim:
a. Percentage of patients on antibiotics given education on 24-hour treatment prior to returning to work, school or day care.
b. Percentage of patients with negative RST or STCX given education concerning home remedies.
c. Percentage of patients with negative RST or STCX given education concerning time schedule to call back if symptoms do not improve in 5-7 days.
d. Percentage of patients prescribed antibiotics who are educated on taking the complete course.
Clinical Algorithm & Annotations
1. Patient > 3 Years Old Complains of Sore
Throat
2. Serious Symptoms?
3. See Physician Based on Severity of Symptoms
4. Complicating Factors?
5. Consult Provider
6. Symptoms of VURI?
7. VURI Guideline
8. Patient on Antibiotic for Other Condition(s)
9. Education
10. Rapid Strep Test (RST) or Strep Throat Culture (STCX)
if RST Not Available or Negative
11. Test Positive?
12. Educate on Non-Strep Pharyngitis and Home Remedies
13. Treatment
14. Educate on Strep Pharyngitis
1. Patient > 3 Years Old Complains of Sore Throat
Symptoms typically associated with group A beta streptococcal (GABS) pharyngitis:
1. Sudden onset of sore throat
2. Exudative tonsillitis
3. Tender anterior cervical adenopathy
4. History of fever
5. Headache
6. Abdominal pain
Symptoms sometimes associated with streptococcal pharyngitis:
1. Vomiting
2. Malaise
3. Anorexia
4. Rash or urticaria
Patients with recent strep exposure may be more likely to have streptococcal pharyngitis.
This guideline should not be applied to children < 3 years of age.
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This guideline is not intended to supercede or preclude clinical judgment.
1. Stridor
2. Respiratory distress (not due to congestion)
3. Air hunger
4. Drooling
5. Inability to swallow liquids
6. Trismus (inability to open the mouth fully)
7. Severity of symptoms judged worrisome at triage.
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3. See Physician Based on Severity of Symptoms
The patient should be seen or evaluated by a physician immediately if serious symptoms are present.
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This guideline applies to patients in generally good health and not at risk. Patients with the following conditions may be included in this guideline after consultation with a provider.
1. History of Rheumatic Fever
2. HIV positive
3. Patient on chemotherapy
4. Immunosuppressed
5. Diabetes Mellitus
6. Pregnant
7. Patient started antibiotics prior to diagnosis
8. Sore throat for > 5 days duration
9. Persistent infection/treatment failure - recurrence of symptoms within 7 days of completing antibiotic therapy
10. Recurrent streptococcal pharyngitis - recurrence of culture positive GABS pharyngitis more than 7 days but within 4 weeks of completing antibiotic therapy.
Strength of the evidence for these recommendations:
#7. Prior start of antibiotics: A.
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Triage staff must consult provider to determine a patient's appropriateness to follow this guideline.
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As stated in the ICSI Viral Upper Respiratory Infection (VURI) guidelines the symptoms of a viral upper respiratory tract infection include:
1. Nasal congestion and discharge
2. Cough
3. Hoarseness
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Streptococcal pharyngitis is unlikely with symptoms of congestion, cough or hoarseness. Patients should be triaged through the ICSI VURI guideline.
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8. Patient on Antibiotic for other Condition(s)?
Patients currently on anti-streptococcal antibiotics are unlikely to have streptococcal pharyngitis and likely do not have the disease. Antibiotics not reliably anti-streptococcal include sulfa medications (Septra, Bactrim, Gantrisin), nitrofurantoin (Macrodantin) and tetracycline.
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When a patient currently on antibiotics (other than sulfa, tetracycline, nitrofurantoin or other non-strep antibiotics) is taking the medication as prescribed and develops a sore throat, chances are that the sore throat is caused by something other than GABS. Treatment failure for GABS is rare. Education will be needed on home remedies for sore throats.
Home remedies include:
· Take acetaminophen or ibuprofen. Do not use aspirin with children and teenagers because it may increase the risk of Reyes Syndrome.
· Gargle with warm salt water (1/4 tsp of salt per 8 oz glass of water).
· Adults or older children may suck on throat lozenges, hard candy or ice. Gargling with ice water can be soothing.
· Eat soft foods. Drink cool beverages or warm liquids.
· Suck on flavored frozen desserts (such as popsicles).
The patient should be instructed to call back if the symptoms worsen or if they persist beyond 5-7 days.
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10. Rapid Strep Test (RST) or Strep Throat Culture (STCX) if RST not Available or Negative
· Perform RST and treat based on results.
RST and STCX both require proper collection technique by trained professionals and must be performed according to the Federal Clinical Laboratory Improvement Act (CLIA) regulations. Poor collection procedures reduce accuracy of either test. RST must also be performed according to the manufacturer's guidelines. An appropriately performed throat swab touches both tonsillar pillars and the posterior pharyngeal wall. The tongue should not be included (although its avoidance is sometimes technically impossible). Backup STCX is needed if RST is negative. The best yield is obtained by using separate swabs for RST and STCX.
If RST is not available, STCX (culture to determine the absence or presence of GABS) should be performed. Generally treatment should be delayed until STCX results are available. Results are usually available within 24 hours or slightly less, but may require incubation for longer periods of time. Some clinicians choose to initiate treatment prior to culture result availability, but a full course of treatment should not be prescribed until culture results confirm the presence of GABS.
A less satisfactory strategy is empiric treatment. Using complex clinical scoring systems or in patients with the complete constellation of classic strep symptoms, empiric treatment may be justified, but has significant limitations. If full course treatment is initiated without intent to rely on the test results, laboratory testing is redundant and wasteful. Routinely culturing and prescribing antibiotic treatment for asymptomatic family members is not recommended. Routinely reculturing patients after treatment with antibiotics is not recommended.
Strength of the evidence for these recommendations:
Clinical scoring systems: B.
RST and STCX: B.
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Whether or not the test is positive, patients and their families want to know results as soon as possible so that they can appropriately plan for their needs.
· If negative, they need educational information and a planned course of action if they do not recover in a reasonable time frame or if they become more ill.
· If positive, patients want to be started on medication as rapidly as possible, primarily as a comfort or convenience issue and to reduce contagion. Rheumatic fever prophylaxis is likely satisfactory if started within a week of the positive culture; however, patients and parents may perceive any delay in initiation of treatment as poor service.
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12. Educate on Non-Strep Pharyngitis and Home Remedies
If the RST or the STCX is negative, the patient needs to be educated on non-strep sore throats. This includes the duration of the symptoms, ineffectiveness of antibiotic treatment and home remedies that will ease the symptoms. The patient should be instructed to call back if the symptoms worsen or if they persist beyond 5-7 days.
Home remedies include:
· Take acetaminophen or ibuprofen. Do not use aspirin with children or teenagers because it may increase the risk of Reyes Syndrome.
· Gargle with warm salt water (1/4 tsp of salt per 8 oz glass of water).
· Adults or older children may suck on throat lozenges, hard candy or ice. Gargling with ice water can be soothing.
· Eat soft foods. Drink cool beverages or warm liquids.
· Suck on flavored frozen desserts (such as popsicles).
Provide educational material about non-strep causes of sore throats and home remedies for the patient to take home.
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Primary episodes
· Penicillin is the drug of choice for treatment of culture positive cases of GABS pharyngitis.
· If the possibility of poor compliance is a concern, IM penicillin may be advisable.
· In penicillin allergic patients, erythromycin is the drug of choice. If the adverse reaction was not anaphylaxis, cephalexin is still a reasonable choice.
· In penicillin and erythromycin allergic patients, consideration should be given to spectrum and cost of antibiotic chosen.
· Although the broader spectrum penicillins, such as ampicillin and amoxicillin, are often used for treatment of GABS pharyngitis, they offer no microbiologic advantage over the narrower spectrum penicillin.
Persistent Infections/Treatment Failure
· Treatment of persistent infection should be directed toward eradication of both GABS and Beta lactamase - producing protective organisms.
Note: All episodes consist of clinical findings and positive lab tests within 7 days after completion of a course of antibiotic therapy.
· Recommendations:
Erythromycin
Cephalexin
Clindamycin
Amoxicillin/clavulanate
Carrier state is briefly discussed in the Discussion and References for this annotation.
Antibiotic Treatment Table
· Although the broader spectrum penicillins, such as ampicillin and amoxicillin, are often used for treatment of GABS pharyngitis, they offer no microbiologic advantage over the narrower spectrum penicillin.
Strength of the evidence for these recommendations:
Use of penicillin: B.
Use of erythromycin: B.
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14. Educate on Strep Pharyngitis
When the strep screen is positive it is important for the patient or care giver to understand the course of the illness and the importance of taking the complete course of antibiotics. They should be aware that they are "contagious" until they have been on the antibiotic for 24 hours, and that they should see improvement in their acute symptoms within 48 hours. It is vital for them to continue the antibiotics for the full course of treatment even when they feel completely better in order to prevent the occurrence of rheumatic fever. They should call their health care provider if they are not feeling significantly better or if their symptoms persist or worsen after 48 hours, or if other members of the family show the same symptoms.
Home remedies include:
· Take acetaminophen or ibuprofen. Do not use aspirin with children or teenagers because it may increase the risk of Reyes Syndrome.
· Gargle with warm salt water (1/4 tsp of salt per 8 oz glass of water).
· Adults or older children may suck on throat lozenges, hard candy or ice. Gargling with ice water can be soothing.
· Eat soft foods. Drink cool beverages or warm liquids.
· Suck on flavored frozen desserts (such as popsicles).
Provide educational material and antibiotic chart for the patient to take home.
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Grade A: Conclusion based on a randomized, controlled trial that has been published in a peer-reviewed journal.
Grade B: Conclusion based on one of the following study types published in a peer-reviewed journal (but not on a randomized, controlled trial):
· a trial using historical or other non-randomized controls;
· a prospective cohort study;
· a case-control study; or
· a meta-analytic study.
Grade C: Conclusion based on one of the following (but not on any studies of the types mentioned above):
· an uncontrolled case series; or
· medical opinion.
Guidelines obtained from the Agency for Health Care Policy and Research (AHCPR) or other sources, position statements, panel consensus statements from the National Institutes of Health (NIH) or elsewhere, review articles, and textbook chapters that cite primary evidence are not assigned a grade because they are not primary evidence. The individual studies cited in such secondary sources can be graded according to the categories presented above.
Other Guidelines Referenced Within This Guideline
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