Pharyngitis medical therapy: Difference between revisions

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{{Pharyngitis}}
{{Pharyngitis}}
{{CMG}}
{{CMG}}; {{AE}} {{chetan}}, {{VSKP}}
 
==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 [[Group A streptococcal|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.


==Medical Therapy==
==Medical Therapy==
There are three types of treatment: '''symptomatic''', '''remedial''' and '''preventive'''. Symptomatic treatments are aimed at reducing pain and symptoms.  Remedial treatments attempt to cure pharyngitis by reducing its spread and speeding up the healing process.  Preventive treatments attempt to block the start of an infection. 
*[[Acute pharyngitis]] should be treated according to the etiologic agent.<ref name="pmid23091044">Shulman ST, Bisno AL, Clegg HW, Gerber MA, Kaplan EL, Lee G et al. (2012) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=23091044 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. [http://dx.doi.org/10.1093/cid/cis847 DOI:10.1093/cid/cis847] PMID: [https://pubmed.gov/23091044 23091044]</ref>
 
Remedial treatments are mostly effective for bacterial infections such as streptococcal infections.  For viral infections, even with treatment, most cases of pharyngitis will still settle spontaneously within a few days. Hence the most popular method of treatment is symptomatic. Many preventive treatments are also remedial, thus those two treatments will be listed in the same section.
 
Twenty-two non-antibiotic managements for sore throat have been studied in controlled trials.<!--
  --><ref name="Thomas">{{cite journal | author= Thomas M, Del Mar CB, Glasziou P. | title=How effective are treatments other than antibiotics for acute sore throat? | journal=Br J GP| year=2000 | volume=50 | issue=459 | pages=817-820| id = PMID 11127175 | url=http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1313826&blobtype=pdf | format=PDF}}</ref><!--  -->Analgesics are among the most effective, but there are many simple measures that can also be used.


===Symptomatic treatments===
*As [[viral]] infections are the most common causes of [[pharyngitis]] in children, most patients do not require treatment and only need [[supportive care]].<ref name="pmid8637780">Bisno AL (1996) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8637780 Acute pharyngitis: etiology and diagnosis.] ''Pediatrics'' 97 (6 Pt 2):949-54. PMID: [https://pubmed.gov/8637780 8637780]</ref>
* Analgesics such as [[NSAIDs]] can help reduce the pain associated with a sore throat.<ref name="Thomas"/>
* [[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 an acute sore throat, the most important clinical task is to decide whether or not the patient has “strep throat.”<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
* [[Throat lozenge]]s ([[cough medicine]]) are often used for short-term pain relief.
* Avoid foods and liquids highly acidic in nature, as they will provoke temporary periods of intense pain.
* Warm tea ([[tea|true]] or Tisane) or soup can help temporarily alleviate the pain of a sore throat.
* Cold beverages, popsicles and ice cubes numb the nerves of the throat somewhat, alleviating the pain for a brief time.  
* Mouthwash (when gargled) reduces the pain but only for a brief time.
* Drinking heavy amounts of liquid reduces the pain for a short time.
* Peppermint candy might help with some cases as well as other hard candies. It will reduce the pain for a short time.
* Yogurt has been shown to help alleviate the pain temporarily by coating the affected area. Milk also has the same effect.
* [[Gargling]] with warm saline solution may help reduce mucus. <ref>{{cite web |url=http://www.mayoclinic.com/health/sore-throat/DS00526/DSECTION=10|title=Sore throat: Self-care - MayoClinic.com |accessdate=2007-09-17 |format= |work=}}</ref> While it is a popular household remedy, there is little evidence that it provides any long-term benefit.


===Remedial and preventive treatments===
===Corticosteroids===
Performing remedial treatments early when a patient's throat begins to feel scratchy may help the infection from spreading to the rest of the throat and back of the mouth, which can result in difficulty in swallowing. Treatment should begin the first or second day of the illness, however if the patient has a cold or the flu, the infection may still continue to spread to other areas such as the ears through the [[eustachian tube]] (causing an earache) and to the lungs through the [[trachea]] (causing a cough).  Healthy people who will be in frequent contact with someone with pharyngitis may also try the measures below, of which some can be also be preventive, to help inhibit the start of an infection. 
[[Corticosteroids]] have been studied and recommended by a guideline<ref name="pmid28931507">{{cite journal| author=Aertgeerts B, Agoritsas T, Siemieniuk RAC, Burgers J, Bekkering GE, Merglen A et al.| title=Corticosteroids for sore throat: a clinical practice guideline. | journal=BMJ | year= 2017 | volume= 358 | issue= | pages= j4090 | pmid=28931507 | doi=10.1136/bmj.j4090 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28931507  }} [http://annals.org/aim/fullarticle/2669671/guideline-experts-recommend-single-dose-oral-steroids-pain-relief-acute ACPJC review]</ref>, but results were heterogeneous in a [[meta-analysis]]<ref name="pmid28931508">{{cite journal| author=Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, Papola D, Lytvyn L, Vandvik PO et al.| title=Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. | journal=BMJ | year= 2017 | volume= 358 | issue=  | pages= j3887 | pmid=28931508 | doi=10.1136/bmj.j3887 | pmc=5605780 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28931508  }} </ref>.  
* The use of [[antibiotic]]s is a helpful remedial treatment when a bacterial infection is the cause of the sore throat. For viral sore throats, antibiotics have no effect.
* Honey has long been used for treating sore throats due to its [[antiseptic]] properties.<ref>{{cite journal |author=Ramoutsaki I, Papadakis C, Ramoutsakis I, Helidonis E |title=Therapeutic methods used for otolaryngological problems during the Byzantine period |journal=Ann. Otol. Rhinol. Laryngol. |volume=111|issue=6 |pages=553-7 |year=2002 |pmid=12090712}}</ref>
* Swallowing a couple teaspoons of raw lemon or lime juice several times a day may help destroy microorganisms in bacteria-related throat infections.<ref name="urlUSE OF CITRIC ACID AS ANTIMICROBIAL AGENT OR ENHANCER OR AS ANTICANCER AGENT - SHANBROM TECH LLC">{{cite web |url=http://www.freepatentsonline.com/EP1331947.html |title=USE OF CITRIC ACID AS ANTIMICROBIAL AGENT OR ENHANCER OR AS ANTICANCER AGENT - SHANBROM TECH LLC |format= |work= |accessdate=}}</ref> Research also shows that lemon juice may destroy some viruses such as HIV.<ref name="urlLemon juice may kill AIDS virus: research - ABC News (Australian Broadcasting Corporation)">{{cite web |url=http://www.abc.net.au/news/stories/2004/07/12/1152319.htm |title=Lemon juice may kill AIDS virus: research - ABC News (Australian Broadcasting Corporation) |format= |work= |accessdate=}}</ref> This remedy should be started during the first or second day of sickness because citric acid can irritate a patient's throat tissues after pharyngitis becomes too widespread.  If this is the case, the patient may try a diluted solution of lemon, honey and tea (or lemon with hot water).


===Medical treatment for Acute Pharyngitis===
The most recent trial in the meta-analysis showed<ref name="pmid28418482">{{cite journal| author=Hayward GN, Hay AD, Moore MV, Jawad S, Williams N, Voysey M | display-authors=etal| title=Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial. | journal=JAMA | year= 2017 | volume= 317 | issue= 15 | pages= 1535-1543 | pmid=28418482 | doi=10.1001/jama.2017.3417 | pmc=5470351 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28418482  }}  [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=28806797 Review in: Ann Intern Med. 2017 Aug 15;167(4):JC16] </ref>:
* Insignificant benefit in the primary outcome at 24 hours. [[Risk difference]] of 4.7% (95% CI, −1.8% to 11.2%)
* Significant benefit at the secondary outcome of 48 hours. [[Risk difference]] of 8.7% (95% CI, 1.2% to 16.2%)


===Other Treatment Regimen===
{| class="wikitable"
|-
! style="width: 34%;" | '''Supportive Therapies'''
! style="width: 33%;" | '''Systemic Therapy'''
! style="width: 33%;" | '''Antimicrobial Regimens'''
|-
| valign="top" |
'''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.<ref name="pmid10767923">Patel SK, Ghufoor K, Jayaraj SM, McPartlin DW, Philpott J (1999) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=10767923 Pictorial assessment of the delivery of oropharyngeal rinse versus oropharyngeal spray.] ''J Laryngol Otol'' 113 (12):1092-4. PMID: [https://pubmed.gov/10767923 10767923]</ref>
'''Oral rinses'''
*Saltwater gargles do not demonstrate any benefit in relieving throat pain. There are minimal side effects associated with these oral rinses.
*[[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.<ref name="pmid3382075">Hess GP, Walson PD (1988) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=3382075 Seizures secondary to oral viscous lidocaine.] ''Ann Emerg Med'' 17 (7):725-7. PMID: [https://pubmed.gov/3382075 3382075]</ref><ref name="pmid7899121">Gonzalez del Rey J, Wason S, Druckenbrod RW (1994) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7899121 Lidocaine overdose: another preventable case?] ''Pediatr Emerg Care'' 10 (6):344-6. PMID: [https://pubmed.gov/7899121 7899121]</ref>
*[[Benzydamine]] hydrochloride rinses have shown to help reduce the pain in a few cases. However, they are used more frequently to treat radiation mucositis.<ref name="pmid7600413">Turnbull RS (1995) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=7600413 Benzydamine Hydrochloride (Tantum) in the management of oral inflammatory conditions.] ''J Can Dent Assoc'' 61 (2):127-34. PMID: [https://pubmed.gov/7600413 7600413]</ref><ref name="pmid11589263">Passàli D, Volonté M, Passàli GC, Damiani V, Bellussi L, MISTRAL Italian Study Group (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11589263 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: [https://pubmed.gov/11589263 11589263]</ref>
'''Sprays'''
*Topical [[anesthetic]] sprays have been used in the past to treat pharyngitis, however, their effect is not significant. They may also cause a few [[allergic]] reactions and side effects, such as [[methemoglobinemia]], and should not be used in children.
*[[Chlorhexidine]] / [[benzydamine]] sprays are more effective in alleviating symptoms of acute [[viral pharyngitis]] and group A streptococcal pharyngitis.<ref name="pmid21310101">Cingi C, Songu M, Ural A, Erdogmus N, Yildirim M, Cakli H et al. (2011) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21310101 Effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray on clinical signs and quality of life of patients with streptococcal tonsillopharyngitis: a multicentre, prospective, randomized, double-blinded, placebo-controlled study.] ''J Laryngol Otol'' 125 (6):620-5. [http://dx.doi.org/10.1017/S0022215111000065 DOI:10.1017/S0022215111000065] PMID: [https://pubmed.gov/21310101 21310101]</ref><ref name="pmid21086279">Cingi C, Songu M, Ural A, Yildirim M, Erdogmus N, Bal C (2010) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=21086279 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: [https://pubmed.gov/21086279 21086279]</ref>
'''Lozenges'''
*Medical throat [[lozenges]] help reducing the duration of symptoms and also provide with some symptomatic relief. They are not recommended for children, as there is a risk of choking. [[Lozenges]] containing [[antiseptics]], [[menthol]], [[anesthetics]], and [[anti-inflammatory]] agents have been used.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>. Flurbiprofen (trade name Strefen) lozenges may help<ref name="pmid11198725">Watson N, Nimmo WS, Christian J, Charlesworth A, Speight J, Miller K (2000) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11198725 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: [https://pubmed.gov/11198725 11198725]</ref>.  [[Amylmetacresol]] and [[2,4-Dichlorobenzylalcohol]] (AMC/DCBA) lozenges (trade names [[Strepsils]], [[Lorsept]], and [[Gorpils]]) may help<ref name="pmid28869700">{{cite journal| author=Weckmann G, Hauptmann-Voß A, Baumeister SE, Klötzer C, Chenot JF| title=Efficacy of AMC/DCBA lozenges for sore throat: A systematic review and meta-analysis. | journal=Int J Clin Pract | year= 2017 | volume=  | issue=  | pages=  | pmid=28869700 | doi=10.1111/ijcp.13002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28869700  }} </ref>.
| valign="top" |
'''Analgesics'''
* [[Analgesics]] are prescribed for moderate to severe pain. [[Acetaminophen]], [[Nonsteroidal anti-inflammatory]]  drugs ([[NSAID]]s) have shown to decrease pain symptoms. They may also help in reducing [[fever]] and [[inflammation]].<ref name="pmid11127175">Thomas M, Del Mar C, Glasziou P (2000) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11127175 How effective are treatments other than antibiotics for acute sore throat?] ''Br J Gen Pract'' 50 (459):817-20. PMID: [https://pubmed.gov/11127175 11127175]</ref><ref name="pmid17535039">Gehanno P, Dreiser RL, Ionescu E, Gold M, Liu JM (2003) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=17535039 Lowest effective single dose of diclofenac for antipyretic and analgesic effects in acute febrile sore throat.] ''Clin Drug Investig'' 23 (4):263-71. PMID: [https://pubmed.gov/17535039 17535039]</ref> [[Aspirin]] should be avoided in children as it may cause [[Reye's syndrome]]. For severe pain, [[codeine]] may be added to the [[NSAID]].
'''Glucocorticoids'''
* [[Glucocorticoid]]s 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.<ref name="pmid15753273">Olympia RP, Khine H, Avner JR (2005) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=15753273 Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children.] ''Arch Pediatr Adolesc Med'' 159 (3):278-82. [http://dx.doi.org/10.1001/archpedi.159.3.278 DOI:10.1001/archpedi.159.3.278] PMID: [https://pubmed.gov/15753273 15753273]</ref><ref name="pmid8427434">O'Brien JF, Meade JL, Falk JL (1993) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=8427434 Dexamethasone as adjuvant therapy for severe acute pharyngitis.] ''Ann Emerg Med'' 22 (2):212-5. PMID: [https://pubmed.gov/8427434 8427434]</ref><ref name="pmid12712025">Bulloch B, Kabani A, Tenenbein M (2003) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=12712025 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. [http://dx.doi.org/10.1067/mem.2003.136 DOI:10.1067/mem.2003.136] PMID: [https://pubmed.gov/12712025 12712025]</ref> Because there are safer and more effective alternatives than [[glucocorticoids]] for pain relief associated with fewer side effects, they not recommended for symptomatic relief of throat pain.


====Systemic Therapy====
| valign="top" |
#Analgesics
'''Streptococcal pharyngitis'''<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
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.<ref name="Thomas-2000">{{Cite journal  | last1 = Thomas | first1 = M. | last2 = Del Mar | first2 = C. | last3 = Glasziou | first3 = P. | title = How effective are treatments other than antibiotics for acute sore throat? | journal = Br J Gen Pract | volume = 50 | issue = 459 | pages = 817-20 | month = Oct | year = 2000 | doi =  | PMID = 11127175 }}</ref><ref name="Gehanno-2003">{{Cite journal  | last1 = Gehanno | first1 = P. | last2 = Dreiser | first2 = RL. | last3 = Ionescu | first3 = E. | last4 = Gold | first4 = M. | last5 = Liu | first5 = JM. | title = Lowest effective single dose of diclofenac for antipyretic and analgesic effects in acute febrile sore throat. | journal = Clin Drug Investig | volume = 23 | issue = 4 | pages = 263-71 | month = | year = 2003 | doi =  | PMID = 17535039 }}</ref><ref name="Schachtel-1993">{{Cite journal  | last1 = Schachtel | first1 = BP. | last2 = Thoden | first2 = WR. | title = A placebo-controlled model for assaying systemic analgesics in children. | journal = Clin Pharmacol Ther | volume = 53 | issue = 5 | pages = 593-601 | month = May | year = 1993 | doi =  | PMID = 8491069 }}</ref><ref name="Bertin-1991">{{Cite journal  | last1 = Bertin | first1 = L. | last2 = Pons | first2 = G. | last3 = d'Athis | first3 = P. | last4 = Lasfargues | first4 = G. | last5 = Maudelonde | first5 = C. | last6 = Duhamel | first6 = JF. | last7 = Olive | first7 = G. | title = Randomized, double-blind, multicenter, controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children. | journal = J Pediatr | volume = 119 | issue = 5 | pages = 811-4 | month = Nov | year = 1991 | doi =  | PMID = 1941391 }}</ref><ref name="Benarrosh-">{{Cite journal  | last1 = Benarrosh | first1 = C. | title = [Multicenter double blind study of tiaprofenic acid versus placebo in tonsillitis and pharyngitis in children]. | journal = Arch Fr Pediatr | volume = 46 | issue = 7 | pages = 541-6 | month =  | year =  | doi =  | PMID = 2688592 }}</ref><ref name="Eccles-2003">{{Cite journal  | last1 = Eccles | first1 = R. | last2 = Loose | first2 = I. | last3 = Jawad | first3 = M. | last4 = Nyman | first4 = L. | title = Effects of acetylsalicylic acid on sore throat pain and other pain symptoms associated with acute upper respiratory tract infection. | journal = Pain Med | volume = 4 | issue = 2 | pages = 118-24 | month = Jun | year = 2003 | doi =  | PMID = 12873261 }}</ref>Aspirin should be avoided in children as it may cause Reye's syndrome .Only for severe pain codeine may be added to the NSAID.
*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): [[Penicillin G|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.<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
*[[Neisseria gonorrhoeae]]: If uncomplicated<ref name="pmid11172144">Bisno AL (2001) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11172144 Acute pharyngitis.] ''N Engl J Med'' 344 (3):205-11. [http://dx.doi.org/10.1056/NEJM200101183440308 DOI:10.1056/NEJM200101183440308] PMID: [https://pubmed.gov/11172144 11172144]</ref>
**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.
|}


#Glucocorticoids
==Chronic Carriers of Group A Streptococci==
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.<ref name="Olympia-2005">{{Cite journal  | last1 = Olympia | first1 = RP. | last2 = Khine | first2 = H. | last3 = Avner | first3 = JR. | title = Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children. | journal = Arch Pediatr Adolesc Med | volume = 159 | issue = 3 | pages = 278-82 | month = Mar | year = 2005 | doi = 10.1001/archpedi.159.3.278 | PMID = 15753273 }}</ref><ref name="O'Brien-1993">{{Cite journal  | last1 = O'Brien | first1 = JF. | last2 = Meade | first2 = JL. | last3 = Falk | first3 = JL. | title = Dexamethasone as adjuvant therapy for severe acute pharyngitis. | journal = Ann Emerg Med | volume = 22 | issue = 2 | pages = 212-5 | month = Feb | year = 1993 | doi =  | PMID = 8427434 }}</ref><ref name="Bulloch-2003">{{Cite journal  | last1 = Bulloch | first1 = B. | last2 = Kabani | first2 = A. | last3 = Tenenbein | first3 = M. | title = Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial. | journal = Ann Emerg Med | volume = 41 | issue = 5 | pages = 601-8 | month = May | year = 2003 | doi = 10.1067/mem.2003.136 | PMID = 12712025 }}</ref><ref name="Marvez-Valls-2002">{{Cite journal  | last1 = Marvez-Valls | first1 = EG. | last2 = Stuckey | first2 = A. | last3 = Ernst | first3 = AA. | title = A randomized clinical trial of oral versus intramuscular delivery of steroids in acute exudative pharyngitis. | journal = Acad Emerg Med | volume = 9 | issue = 1 | pages = 9-14 | month = Jan | year = 2002 | doi =  | PMID = 11772663 }}</ref><ref name="Roy-2004">{{Cite journal  | last1 = Roy | first1 = M. | last2 = Bailey | first2 = B. | last3 = Amre | first3 = DK. | last4 = Girodias | first4 = JB. | last5 = Bussières | first5 = JF. | last6 = Gaudreault | first6 = P. | title = Dexamethasone for the treatment of sore throat in children with suspected infectious mononucleosis: a randomized, double-blind, placebo-controlled, clinical trial. | journal = Arch Pediatr Adolesc Med | volume = 158 | issue = 3 | pages = 250-4 | month = Mar | year = 2004 | doi = 10.1001/archpedi.158.3.250 | PMID = 14993084 }}</ref><ref name="Niland-2006">{{Cite journal  | last1 = Niland | first1 = ML. | last2 = Bonsu | first2 = BK. | last3 = Nuss | first3 = KE. | last4 = Goodman | first4 = DG. | title = A pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis. | journal = Pediatr Infect Dis J | volume = 25 | issue = 6 | pages = 477-81 | month = Jun | year = 2006 | doi = 10.1097/01.inf.0000219469.95772.3f | PMID = 16732143 }}</ref><ref name="Wing-2010">{{Cite journal  | last1 = Wing | first1 = A. | last2 = Villa-Roel | first2 = C. | last3 = Yeh | first3 = B. | last4 = Eskin | first4 = B. | last5 = Buckingham | first5 = J. | last6 = Rowe | first6 = BH. | title = Effectiveness of corticosteroid treatment in acute pharyngitis: a systematic review of the literature. | journal = Acad Emerg Med | volume = 17 | issue = 5 | pages = 476-83 | month = May | year = 2010 | doi = 10.1111/j.1553-2712.2010.00723.x | PMID = 20536799 }}</ref><ref name="Hayward-2012">{{Cite journal  | last1 = Hayward | first1 = G. | last2 = Thompson | first2 = MJ. | last3 = Perera | first3 = R. | last4 = Glasziou | first4 = PP. | last5 = Del Mar | first5 = CB. | last6 = Heneghan | first6 = CJ. | title = Corticosteroids as standalone or add-on treatment for sore throat. | journal = Cochrane Database Syst Rev | volume = 10 | issue =  | pages = CD008268 | month =  | year = 2012 | doi = 10.1002/14651858.CD008268.pub2 | PMID = 23076943 }}</ref>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 recommendedfor symptomatic relief of throat pain.However in a few conditions like infectious mononucleosis a short term may  be help in alleviating pain.
Antimicrobial therapy is not indicated for the majority of chronic carriers. A few conditions where antibiotics are recommended are:
#An outbreak of [[rheumatic fever]], acute [[poststreptococcal glomerulonephritis]] or invasive GAS infection
#Closed community outbreak of GAS pharyngitis
#Family history of [[acute rheumatic fever]]
#Excessive anxiety about [[rheumatic fever]]


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


[[Category:Emergency medicine]]
[[Category:Emergency mdicine]]
[[Category:Primary care]]
[[Category:Disease]]
[[Category:Up-To-Date]]
[[Category:Infectious disease]]
[[Category:Infectious disease]]
[[Category:Inflammations]]
[[Category:Otolaryngology]]
[[Category:Otolaryngology]]
[[Category:Pulmonology]]
[[Category:Pediatrics]]
[[Category:Signs and symptoms]]
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Latest revision as of 22:48, 11 December 2020

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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.

Medical Therapy

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

Corticosteroids

Corticosteroids have been studied and recommended by a guideline[4], but results were heterogeneous in a meta-analysis[5].

The most recent trial in the meta-analysis showed[6]:

  • Insignificant benefit in the primary outcome at 24 hours. Risk difference of 4.7% (95% CI, −1.8% to 11.2%)
  • Significant benefit at the secondary outcome of 48 hours. Risk difference of 8.7% (95% CI, 1.2% to 16.2%)

Other Treatment Regimen

Supportive Therapies Systemic Therapy Antimicrobial Regimens

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.[7]

Oral rinses

  • Saltwater gargles do not demonstrate any benefit in relieving throat pain. There are minimal side effects associated with these oral rinses.
  • 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.[8][9]
  • Benzydamine hydrochloride rinses have shown to help reduce the pain in a few cases. However, they are used more frequently to treat radiation mucositis.[10][11]

Sprays

Lozenges

Analgesics

Glucocorticoids

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

Chronic Carriers of Group A Streptococci

Antimicrobial therapy is not indicated for the 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

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
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Bisno AL (2001) Acute pharyngitis. N Engl J Med 344 (3):205-11. DOI:10.1056/NEJM200101183440308 PMID: 11172144
  4. ↑ Aertgeerts B, Agoritsas T, Siemieniuk RAC, Burgers J, Bekkering GE, Merglen A; et al. (2017). "Corticosteroids for sore throat: a clinical practice guideline". BMJ. 358: j4090. doi:10.1136/bmj.j4090. PMID 28931507. ACPJC review
  5. ↑ Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, Papola D, Lytvyn L, Vandvik PO; et al. (2017). "Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials". BMJ. 358: j3887. doi:10.1136/bmj.j3887. PMC 5605780. PMID 28931508.
  6. ↑ Hayward GN, Hay AD, Moore MV, Jawad S, Williams N, Voysey M; et al. (2017). "Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial". JAMA. 317 (15): 1535–1543. doi:10.1001/jama.2017.3417. PMC 5470351. PMID 28418482. Review in: Ann Intern Med. 2017 Aug 15;167(4):JC16
  7. ↑ 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
  8. ↑ Hess GP, Walson PD (1988) Seizures secondary to oral viscous lidocaine. Ann Emerg Med 17 (7):725-7. PMID: 3382075
  9. ↑ Gonzalez del Rey J, Wason S, Druckenbrod RW (1994) Lidocaine overdose: another preventable case? Pediatr Emerg Care 10 (6):344-6. PMID: 7899121
  10. ↑ Turnbull RS (1995) Benzydamine Hydrochloride (Tantum) in the management of oral inflammatory conditions. J Can Dent Assoc 61 (2):127-34. PMID: 7600413
  11. ↑ Passàli D, Volonté M, Passàli GC, Damiani V, Bellussi L, MISTRAL Italian Study Group (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
  12. ↑ Cingi C, Songu M, Ural A, Erdogmus N, Yildirim M, Cakli H et al. (2011) Effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray on clinical signs and quality of life of patients with streptococcal tonsillopharyngitis: a multicentre, prospective, randomized, double-blinded, placebo-controlled study. J Laryngol Otol 125 (6):620-5. DOI:10.1017/S0022215111000065 PMID: 21310101
  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
  14. ↑ 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
  15. ↑ Weckmann G, Hauptmann-Voß A, Baumeister SE, Klötzer C, Chenot JF (2017). "Efficacy of AMC/DCBA lozenges for sore throat: A systematic review and meta-analysis". Int J Clin Pract. doi:10.1111/ijcp.13002. PMID 28869700.
  16. ↑ 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
  17. ↑ 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
  18. ↑ 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
  19. ↑ 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
  20. ↑ 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
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