Tonsillopharyngitis - Acute Management

Evaluation

Assessment For Urgent Care and Hospitalization

Red Flags  

It is important to assess for signs and symptoms of airway obstruction needing urgent management. Red flags that should watch out for are respiratory distress (eg chest retractions, cyanosis, moderate to severe dyspnea, increased respiratory rate, shallow breathing, difficulty swallowing, choking, foreign body inhalation, drooling, dysphonia), altered mental state, decreased consciousness level, severe lethargy, excessive sleepiness with difficulty to stay awake, unresponsiveness, changes in everyday activity (eg refusal to eat and markedly reduced activity), signs of dehydration, no urine output for >12 hours, vomiting, meningeal signs (eg stiff neck, persistent vomiting, severe headache), and petechial or purpuric rash.  

Principles of Therapy

With the exception of very rare infections caused by certain pathogens (eg Corynebacterium diphtheriae, Neisseria gonorrhea), antibiotic therapy is of no proven benefit for acute pharyngitis due to bacteria other than GABS. The first line of therapy is symptomatic therapy as viruses are the most common cause of acute pharyngitis and therefore, antibiotics are not warranted in the majority of cases and antivirals may be indicated.  

Appropriate antibiotic therapy is needed for GABS because of the following reasons:

• Prevention of non-suppurative complications (eg acute rheumatic fever, acute post-streptococcal glomerulonephritis, reactive arthritis) and suppurative complications (eg peritonsillar abscess, mastoiditis, cervical lymphadenitis)
• Minimize transmission
• Shorten the course of illness and allow rapid resumption of the patient’s activities

If there is clinical or epidemiological evidence that results in a high index of suspicion, antimicrobial therapy may be initiated while the physician is waiting for the lab confirmation of GABS pharyngitis. It must be noted that empiric antimicrobial therapy is generally not recommended. GABS pharyngitis is treated as soon as possible after diagnosis in high-risk patients to decrease the risk of complications and period of contagiousness. Empiric antimicrobial therapy for GABS may also be warranted in cases where there is lack of laboratory access, lack of or unreliable patient follow-up, or toxic presentation. Group A Streptococci generally do not require treatment and are not likely to infect contacts or have suppurative or non-suppurative complications. If throat culture is the method of diagnosis, antibiotics are discontinued if the presumptive diagnosis of GABS pharyngitis is not confirmed by laboratory test results. When selecting antimicrobials, efficacy, safety, antimicrobial spectrum, potential adverse and side effects, dosing schedule, associated compliance with therapy, and cost should be considered. Antibiotics may be given orally or parenterally, depending on the condition of the patient and compliance concerns. 

Management of Recurrent Episodes of Acute Pharyngitis  

Single Episodes with Laboratory Confirmation Shortly After Completion of Antibiotic Course 

For those with a single episode with laboratory confirmation shortly after completion of antibiotic course, retreatment with any of the recommended agents for GABS may be done. Agents such as narrow-spectrum cephalosporin, Clindamycin or Amoxicillin/clavulanic acid, or the combination of Penicillin and Rifampin, are reasonable in the treatment of patients with GABS pharyngitis in whom initial Penicillin treatment has failed. IM Benzathine penicillin G if non-compliance is suspected may be considered.  

For Multiple Episodes Over Months or Years  

For cases of multiple episodes over months or years, it may be difficult to differentiate between viral pharyngitis in a Streptococcus sp carrier from a true group A streptococcal pharyngitis. For patients with persistent or recurrent symptoms consistent with GABS and/or positive test result, consider possible non-compliance with the prescribed antimicrobial regimen, recurrent infection (either with the initial infecting strain or a new strain), treatment failure, superimposed infection on chronic GABS carriage or the presence of a suppurative complication (eg peritonsillar abscess). Transmission within families wherein one family member or close contact may be an asymptomatic carrier of GABS is assessed. It has been shown that vaccination against influenza and pneumococcus may result in significant reductions in the number of future episodes of acute sore throat. 

Pharmacological therapy

Symptomatic Therapy  

Symptomatic therapy include:

• Maintain adequate fluid intake
• Warm salt water
• Soft foods
• Warm liquids (eg soup)
• Throat Lozenges or sprays

Antipyretics and Analgesics  

Patients may take Paracetamol for relief of fever and/or joint pain. Paracetamol is the drug of choice for analgesia in sore throat.  

Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

NSAIDs in the form of lozenges and throat sprays are available (eg Flurbiprofen, Benzydamine). Topical application of Flurbiprofen can quickly alleviate and lessen the intensity of symptoms. Systemic NSAIDs (eg Ibuprofen, Diclofenac) are safe and effective alternatives for analgesia and antipyrexia but are associated with significant risk of gastrointestinal (GI) bleeding, their routine use is not recommended.  

Mouth or Throat Preparations  

Mouth or throat preparations may provide symptomatic pain relief of throat pain. Antiseptic or antibacterial preparations may be used to prevent viral and bacterial infection. Further studies are needed to prove the efficacy of mouth or throat preparations in tonsillopharyngitis.

Tonsillopharyngitis - Acute_Management

Nonpharmacological

Patient Education  

If GABS is suspected or confirmed, the patient is instructed to remain at home until at least 24 hours of antimicrobial therapy has been received to minimize transmission of disease. The importance of adhering to the prescribed medication regimen is also emphasized. If common respiratory virus is thought to be the likely cause, provide educational material about non-streptococcal causes of sore throat and home remedies that the patient may use. The patient should be instructed to follow up if the symptoms worsen or if they persist beyond 5-7 days. Advise the patient to eliminate close contact with other people to minimize transmission of the disease. Patients are infectious 2-5 adays before symptom onset, during the illness, and for a week after if untreated. 

If GABS is Suspected or Confirmed  

The patient is instructed to remain at home until at least 24 hours of antimicrobial therapy has been received to minimize transmission of disease. Emphasize the importance of adhering to the prescribed medication regimen.  

Hygiene  

Hand washing, especially after coughing or sneezing and before preparing or eating food prevents other people from getting infected with group A Streptococcus. Washing hands with soap and water for at least 20 seconds and using an alcohol-based hand rub instead if there is no soap available is also done. Other practices of good hygiene include masking, covering the nose and mouth with tissue while coughing or sneezing, properly disposing used tissue in a waste basket, and using the upper sleeve or the elbow of your clothes while coughing or sneezing if there is no tissue.

Surgery

Surgical removal of the tonsils may be considered for patients whose symptomatic episodes do not diminish in frequency over time and for whom no alternative explanation for recurrent pharyngitis is evident.  

It is also considered if the symptoms intervene with patient’s normal daily function and 7 or more episodes of tonsillitis over a 12-month period or 5 or more episodes per year in the past 2 years or 3 or more episodes per year in the past 3 years with documentation for each episode of sore throat and having 1 or more of the following:

• Temperature >38.3°C (101°F)
• Cervical adenopathy
• Tonsillar exudate
• Positive test for GABS infection