ACUTE PHARYNGITIS

A Serious Pain in the Neck . . . . . . . . . . . Level I

LEARNING OBJECTIVES
After completing this case study, the reader should be able to:

• Evaluate the need for antibiotic therapy in a patient with pharyngitis based on signs and symptoms
as well as microbiological and immunological diagnostic studies.
• Identify the most common organisms responsible for causing pharyngitis.
• Select an appropriate pharmacologic regimen for a patient with acute pharyngitis, including route,
frequency, and duration.
• List the suppurative and nonsuppurative complications of acute pharyngitis, as well as the
prevalence of these complications, and the measures to prevent occurrence.

PATIENT PRESENTATION

Chief Complaint
“It hurts to swallow.”

HPI
David Jacobs is a 5-year-old boy who presents to his pediatrician complaining of sore throat. His
mother states he has had fever of 102°F on and off for the past 24 hours and was treated with
acetaminophen. He has also been sleeping more than usual over the past 2 days. He has refused to eat
anything solid since this time but has been drinking liquids. His mother states he does not have a
cough, shortness of breath, or difficulty breathing. The patient mentions that both his stomach and head
aches, but his mother states he has not vomited. Mother notes no recent illness in the family.

PMH
The patient has had prior cases of otitis media, his last over a year ago. Otherwise he is healthy. His
mother states that he is up-to-date on all vaccinations.

FH
Noncontributory

SH
David lives with his parents and infant sister. He attends a local day care and preschool.
 Meds
None

All
Amoxicillin: rash, hives

ROS
Negative except for complaints noted in the HPI

Physical Examination
Gen
WDWN 5-year-old male, clearly fatigued

VS
BP 104/70, P 92, RR 22, T 38.8°C, Wt 21 kg, Ht 45″

Skin
Pale, warm, faint scarlatiniform rash on arms and trunk

HEENT
PERRLA; tonsils erythematous with associated white exudates; uvula edematous; soft palate with
notable petechiae, TM normal

Neck/Lymph Nodes
Multiple enlarged anterior cervical lymph nodes, greater than 2 cm in size

Lungs/Thorax
CTA bilaterally, (–) shortness of breath, (–) cough

CV
RRR, normal S1 and S2

Abd
Soft, nontender, nondistended, (+) BS

Genit/Rect
Deferred

Neuro
CN I–XII intact

Labs
RADT: negative
Throat culture: results pending
 Assessment
A 5-year-old male presents to the pediatrician with suspected group A β-hemolytic streptococcus
(GABHS) pharyngitis.

QUESTIONS

Problem Identification
1.a. What are the signs and symptoms in this patient that are indicative of possible GABHS infection
in comparison with symptoms of viral pharyngitis?
1.b. What diagnostic tool(s) may be used to facilitate a diagnosis? Describe differences in
implementation and sensitivity/specificity between testing methods and how these differences
influence clinical interpretation.
1.c. When can throat culture results be expected to return? Based on clinical interpretation of DJ’s
signs and symptoms, what is the expected result of this culture?

Desired Outcome
2. List the goals of therapy for both treatment and the prevention of clinical and pharmacologic
complications.

Therapeutic Alternatives
3.a. What nonpharmacologic therapies are available for treatment of GABHS acute pharyngitis?
3.b. What are the pharmacologic options for GABHS acute pharyngitis?

Optimal Plan
4.a. Assuming DJ’s throat culture returns positive for GABHS, what is the preferred treatment for
DJ’s acute pharyngitis? Include dose, route, frequency, and duration.
4.b. Which option would be most appropriate if DJ had not reported an amoxicillin allergy?

Outcome Evaluation
5.a. What should be monitored to evaluate successful therapy and/or development of adverse effects?
5.b. What would be the appropriate management strategy if DJ’s infection did not resolve?

Patient Education
6. What information should be shared with DJ and his parents regarding his clinical condition as
well as his drug therapy?

SELF-STUDY ASSIGNMENTS
1. Create a table that lists the preferred and alternative therapeutic options for GABHS pharyngitis
 and includes the following comparative data:
• Drug
• Dose
• Frequency
• Duration
• Available dosage forms
• Adverse effects
• Cost
2. Prepare a one-page paper that describes the incidence, risk factors, signs/symptoms, and onset of
scarlet fever, rheumatic fever, and poststreptococcal glomerulonephritis.

CLINICAL PEARL
While early initiation of antibiotic therapy can reduce the duration of GABHS symptoms, withholding
antibiotics until laboratory confirmation of GABHS bacterial disease in the majority of clinical
circumstances can reduce the potential for inappropriate antibiotic therapy while still preventing the
spread of GABHS to others.

Acknowledgment
This case is based on the case written by John L. Lock, PharmD, BCPS, AQ-ID, for the 9th edition of
the Casebook.

REFERENCES
1. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and
treatment of acute streptococcal pharyngitis. Circulation 2009;119:1541–1551.
2. Shulman ST, Bisno AL, Clegg HW, et al. Practice guidelines for the diagnosis and management of
group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America.
Clin Infect Dis 2012;55:1279–1282.
3. Wessels MR. Streptococcal pharyngitis. N Engl J Med 2011;364:648–655.
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antigen-detection test and throat culture in community pediatric offices: implications for
management of pharyngitis. Pediatrics 2009;123:437–444.
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the management of pharyngitis in children and adults. JAMA 2004;291:1587–1595.
6. Center for Medicare and Medicaid Services. 2014 Clinical Quality Measures (CQMs): Pediatric
Recommended Core Measures. https://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_CQM_PrediatricRecommended_
Accessed March 30, 2016.
7. Tanz RR, Shulman ST, Shortridge VD, et al. Community-based surveillance in the United States of
macrolide-resistant pediatric pharyngeal group A streptococci during 3 respiratory disease
 seasons. Clin Infect Dis 2004;39:1794–1801.
8. Centers for Disease Control and Prevention. Is It Strep Throat?
http://www.cdc.gov/Features/strepthroat/. Accessed March 30, 2016.