Pharyngitis medical therapy

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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.[1]

Medical Therapy

  • Acute pharyngitis should be treated according to the etiologic agent.
  • 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 acute sore throat, the most important clinical task is to decide whether or not the patient has “strep throat.”[3]

Algorithm of Medical therapy for Pharyngitis

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.[4]

Oral rinses

  • Salt water gargles which have been used since a long time have not shown any benefit in releiving throat pain . It is still used as it has minimal side effects.
  • 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.[5][6]
  • Benzydamine hydrochloride rinses have shown to be help reduce the pain in a few cases. However, they are used more frequently to treat radiation mucositis.[7][8]

Sprays

  • Topical anesthetic sprays have been used in the past to treat pharyngitis , however their effect is not signigficant . They may also cause a few allergic reactions and side effects like methemoglobinemia and hence should not be used in children.
  • Chlorhexidine /benzydamine sprays are more effective in alleviating symptoms of acure viral pharyngitis and group A streptococcal pharyngitis.[9][10]

Lozenges

  • Medical throat lozenges help reducing the duration of symptoms and also provide with some sympotomatic relief. They do come with a few side effects similiar to sprays like methemoglobinemia. They are not recommended for children as there is a risk of choking Lozenges containing antisepotics, menthol , anesthetics and antiflammatory agents have been used.[11][12]

Analgesics

  • 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.[13][14]Aspirin should be avoided in children as it may cause Reye's syndrome .Only for severe pain codeine may be added to the NSAID.

Glucocorticoids

  • 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.[15][16][17]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 recommended for symptomatic relief of throat pain.However in a few conditions like infectious mononucleosis a short term may be help in alleviating pain.

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

  • Arcanobacterium haemolyticum: Erythromycin is the preferred drug.[3]
  • Neisseria gonorrhoeae: If uncomplicated[3]
    • 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.

Chronic Carriers of Group A Streptococci

Antimicrobial therapy is not indicated for 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
  5. If tonsillectomy in considered because of carriage.

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. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 3.2 3.3 Bisno AL (2001) Acute pharyngitis. N Engl J Med 344 (3):205-11. DOI:10.1056/NEJM200101183440308 PMID: 11172144
  4. ↑ 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. Unknown parameter |month= ignored (help)
  5. ↑ Hess, GP.; Walson, PD. (1988). "Seizures secondary to oral viscous lidocaine". Ann Emerg Med. 17 (7): 725–7. PMID 3382075. Unknown parameter |month= ignored (help)
  6. ↑ Gonzalez del Rey, J.; Wason, S.; Druckenbrod, RW. (1994). "Lidocaine overdose: another preventable case?". Pediatr Emerg Care. 10 (6): 344–6. PMID 7899121. Unknown parameter |month= ignored (help)
  7. ↑ Turnbull, RS. (1995). "Benzydamine Hydrochloride (Tantum) in the management of oral inflammatory conditions". J Can Dent Assoc. 61 (2): 127–34. PMID 7600413. Unknown parameter |month= ignored (help)
  8. ↑ Passàli, D.; Volonté, M.; Passàli, GC.; Damiani, V.; Bellussi, L. (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. Unknown parameter |month= ignored (help)
  9. ↑ Cingi, C.; Songu, M.; Ural, A.; Erdogmus, N.; Yildirim, M.; Cakli, H.; Bal, C. (2011). "Effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray on clinical signs and quality of life of patients with streptococcal tonsillopharyngitis: multicentre, prospective, randomised, double-blinded, placebo-controlled study". J Laryngol Otol. 125 (6): 620–5. doi:10.1017/S0022215111000065. PMID 21310101. Unknown parameter |month= ignored (help)
  10. ↑ 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. Unknown parameter |month= ignored (help)
  11. ↑ Bisno, AL. (2001). "Acute pharyngitis". N Engl J Med. 344 (3): 205–11. doi:10.1056/NEJM200101183440308. PMID 11172144. Unknown parameter |month= ignored (help)
  12. ↑ 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. Unknown parameter |month= ignored (help)
  13. ↑ 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. Unknown parameter |month= ignored (help)
  14. ↑ 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.
  15. ↑ 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. Unknown parameter |month= ignored (help)
  16. ↑ 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. Unknown parameter |month= ignored (help)
  17. ↑ 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. Unknown parameter |month= ignored (help)
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