QUEST Integration – Pharyngitis, Acute – Treatment for Adults

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Guideline summary

• Viruses are the most common cause of acute pharyngitis
• 10 percent of cases are caused by GABHS and should be treated
• The goal of diagnostic evaluation is to distinguish GABHS
• Reliable predictors of GABHS are Centor criteria:
  1. fever
  2. tonsillar exudates
  3. absence of cough
  4. tender anterior cervical lymphadenopathy
• Rapid antigen test should be performed only with 2 or 3 Centor criteria.
• Limit antibiotics to patients with positive results.
• For patients with 3 to 4 Centor criteria, use antibiotic therapy.
• For GABHS, penicillin therapy is first choice for patients without penicillin allergy.
• Erythromycin is the first choice for penicillin-allergic patients.
• Acute pharyngitis in healthy adults is usually self-limited and rarely produces sequelae.
• Treatment includes appropriate analgesics, antipyretics and supportive care.

Introduction

Acute pharyngitis accounts for one to two percent of all outpatient, office and emergency visits. While a wide range of infectious agents produces acute pharyngitis, viruses are the most common cause. In the vast majority of cases, acute pharyngitis in an otherwise healthy adult is self-limited and rarely produces significant sequelae. Approximately 10 percent of adult cases are caused by Group A b-hemolytic streptococcus (GABHS), and these patients should benefit from antimicrobial therapy.

Goals/desired outcomes

The goal of diagnostic evaluation is to distinguish patients with GABHS pharyngitis and make appropriate antibiotic treatment decisions. Treatment guidelines in this section apply to immunocompetent adults with no history of rheumatic fever and without complicated comorbid conditions such as chronic lung or heart disease. The guidelines do not apply during known outbreaks of Group A streptococcus.

• Provide supportive care to the large majority of adults with acute pharyngitis who have a self-limited illness.
• Provide antibiotic treatment for pharyngitis only for adult patients with GABHS infection. Gonococcal pharyngitis and diphtheria are appropriate for immediate antibiotic treatment and are excluded from discussion in this guideline.
• Offer patients with pharyngitis appropriate doses of analgesics and antipyretics, as well as other supportive care (e.g., gargles).

Diagnosis

Do not use throat culture to diagnose GABHS in an otherwise healthy adult. Other reasonably accurate approaches allow treatment decisions to be made earlier in the course of illness, when patients can receive symptomatic benefit. A clinical screening, including history and physical examination, would identify most patients with GABHS while dramatically decreasing excess antibiotic use.

The most reliable predictors of GABHS pharyngitis are the Centor criteria, which include history of fever, tonsillar exudates, absence of cough, and tender anterior cervical lymphadenopathy. Several studies examining these four criteria in clinical decision-making indicate that in patients who have three or four of the criteria, both the sensitivity and specificity associated with use of the criteria (compared with those of throat culture) are approximately 75 percent.

Rapid antigen tests for GABHS, when compared to throat culture, have widely variable sensitivity and specificity, depending on the type of test and practice setting. Practitioners should consider the economic costs of a few extra prescriptions versus the costs of many extra rapid antigen tests.

It is recommended that rapid antigen tests be performed only in patients with an intermediate clinical probability of GABHS (those with two or three of the four clinical variables), and that antimicrobial agents not be prescribed when test results are negative.

Following are recommended diagnostic procedures:

• Clinically screen all adult patients with pharyngitis for the presence of the four Centor criteria: 1) history of fever, 2) tonsillar exudates, 3) no cough, and 4) tender anterior cervical lymphadenopathy (lymphadenitis).
• Do not test or treat patients who meet one or none of the Centor criteria; such patients are unlikely to have GABHS infections.
• For patients who meet two or three criteria, the following approach is appropriate:
• Test patients by using rapid antigen test.
• Limit antibiotic therapy to patients with positive results.
• For patients who meet three or four criteria, the following approach is appropriate:
• Do not perform diagnostic tests.
• Use antibiotic therapy.
• Do not perform throat culture for the routine primary evaluation of adults with pharyngitis or for confirmation of negative rapid antigen tests when the test sensitivity exceeds 80 percent.

Treatment

Pharyngitis Treatment Algorithm [PDF]

Antimicrobial treatment of GABHS pharyngitis leads to a decreased risk of already rare complications and a decrease in the duration of some patient symptoms by one or two days. Begin treatment within 48 to 72 hours of symptom onset. For otherwise healthy adult patients with GABHS pharyngitis who have an aversion to antimicrobial agents or medications, it is reasonable to provide no antimicrobial treatment and expect few measurable adverse consequences. An appropriate strategy is to limit antimicrobial therapy to the minority of adults who are most likely to benefit from the therapy, such as those with a high likelihood of GABHS pharyngitis.

• Administer appropriate analgesics (topical and systemic), antipyretics and supportive care (e.g., gargles) to all patients with pharyngitis. The overwhelming majority of adults with acute pharyngitis have self-limited illness, which responds well to supportive care only.
• Physicians should limit antimicrobial prescriptions to patients who are most likely to have GABHS. GABHS is the causal agent in 10 percent of adult cases of pharyngitis and antibiotic efficacy is limited to these patients. Either of the following treatment approaches is appropriate:
• Provide empirical antibiotic treatment in adults with at least three of four clinical criteria shown to be associated with GABHS. Do not treat all others.
• Provide empirical treatment of adults with all four clinical criteria. Conduct rapid antigen testing of patients with two or three clinical criteria, followed by treatment of those with positive test results. Do not treat all others.
• Choose an antimicrobial agent with the narrowest possible spectrum of action that still covers GABHS. Penicillin is the first choice for patients without penicillin allergy; erythromycin is the first choice for penicillin-allergic patients. To date, there is no evidence of GABHS resistance to penicillin, and erythromycin resistance rates are low in the United States.

Source

1. Snow V. et al. Principles of Appropriate Antibiotic Use for Acute Pharyngitis in Adults. Annals of Internal Medicine. 2001;134: 506-517.

Clinical practice guidelines serve as an educational reference, and do not supersede the clinical judgment of the treating physician with respect to appropriate and necessary care for an individual patient. In the event HMSA policies differ from the clinical practice guidelines, for benefit purposes, HMSA policies shall supersede the clinical practice guidelines.

Sources

1. University of Michigan Health System. (2006). Pharyngitis. Copyright 2006. University of Michigan Health Systems. Used with permission.
2. Cooper RJ, Hoffman JR, Bartlett JG, Besser RE, Gonzales R, Hickner JM, Sande MA. (2001). Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med, 134(6):509-17.

References

1. Bisno AL, Berber MA, Gwaltney JM, Kaplan EL, Schwartz RH. (2002). Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis, 35(2): 113-25.
2. Institute for Clinical Systems Improvement. (2002). Diagnosis and treatment of respiratory illness in children and adults. Copyright 2004, Institute for Clinical Systems Improvement. Used with permission.

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