SPECIAL THEME
Diagnosis and Management of Acute Tonsillopharyngitis in
Family Practice
Daisy M Medina, MD, FPAFP; Noel M. Espallardo, MD, MSc, FPAFP; Ma. Teresa Tricia G. Bautista, MD, FPAFP
Joan Mae Oliveros, MD, FPAFP; Ma. Rosario Bernardo-Lazaro, MD, MBAH, FPAFP and
Jane Eflyn L. Lardizabal-Bunyi, MD, DFM, FPAFP
Background: Acute tonsillopharyngitis is a common reason for consult in the primary care setting. Although most cases are viral
in etiology, more than half of patients with acute tonsillopharyngitis still receive antibiotic therapy for group A beta-hemolytic
streptococcal infection. Streptococcal throat infection may lead uncommonly to suppurative complications like peritonsillar
abscess and non-suppurative complications like acute rheumatic fever. It is with this consideration that streptococcal throat
infection must be distinguished from viral infections. Clinical practice guidelines have focused their efforts on how it can be
accurately diagnosed to prevent complications while reducing unnecessary antibiotic prescribing.
Objective: This clinical pathway was developed to serve as guidance for family and community medicine practitioners in making
clinical decisions regarding the diagnosis and management of acute tonsillophrayngitis.
Methods: After defining the scope of the pathway, the PAFP Clinical Pathways Group first identified the key issues in managing
patient with acute tonsillopharyngitis. These key issues were then translated to review question. The group then reviewed the
published medical literature to identify, summarize, and operationalize the evidence in clinical publication. Databases were first
searched for existing clinical practice guidelines from reputable medical organizations. Further search for evidence was also
conducted using the terms “tonsillopharyngitis” or “tonsillitis”, “diagnosis” and “treatment”. Evidence was then summarized and
its quality assessed using the modified GRADE approach. From the evidence-based summaries, the CPDG then developed general
guideline and pathway recommendations which are stated as time-bound tasks of patient-care processes in the management of
acute tonsillopharyngitis in family and community practice. The recommendations were then presented to a panel of family and
community practitioners in both urban and rural settings, for a consensus agreement on the applicability of the recommendations
to family and community practice. Lastly, the final clinical pathway was written and developed to include the recommendations,
the clinical pathway tables, and an algorithm. The clinical pathway can be used as a checklist or standards of care. The algorithm
can be used to explain the process of care to the patient
Recommendations: This clinical pathway contains updates on recommendations in the 2010 clinical practice guidelines on
acute tonsillopharyngitis. Recommendations on the utilization of clinical scoring and rapid antigen tests as basis for deciding
on need for antibiotic therapy comprise the major changes from the previously published guidelines. Penicillin remains as the
first-line antibiotic therapy for streptococcal throat infection.
Summary of Recommendations
History and Physical Exam
FIRST VISIT
Elicit history of throat pain and its intensity, fever and painful lymph nodes on the neck and duration of symptoms. (AII)
Elicit history of recurrent tonsillopharyngitis, peritonsillar abscess and drug allergies (AII)
Evaluate socioeconomic status (BII)
Examine for fever, tonsillar swelling, exudates, and cervical lymphadenitis. (AII)
Examine for signs of dehydration (BIII)
Obtain the Centor or FeverPAIN score to determine probability of streptococcal infection (AII)
198
THE FILIPINO FAMILY PHYSICIAN
SECOND VISIT
Re-evaluate the presence of throat pain and its intensity, fever, tonsillopharyngeal congestion, and tonsillar exudates (AII)
Assess adherence to treatment (AII) and explore reasons for non-adherence (AIII)
Ask for presence of any adverse drug event (AIII)
Examine for signs of suppurative complications if with no improvement in symptoms (AII)
Diagnostic Exam
Offer rapid antigen test for Streptococcal infection to patients 3 years of age and older with Centor score of ≥3, if available (CII)
Offer throat swab and culture if initial antibiotic treatment fails (AII)
Pharmacologic Intervention
FIRST VISIT
Offer symptomatic treatment with paracetamol or NSAID in lozenge or oral form. (AI)
In adult patients with more severe presentations e.g Centor score ≥3 , consider offering a single low-dose corticosteroid (AI)
Antibiotics should only be offered if the rapid antigen test is positive or if Centor score is ≥3 or Fever PAIN score is ≥4. Penicillin or
Amoxicillin is given as first-line antibiotic treatment. Cephalosporins and macrolides are given in case of allergies to penicillin (AI)
SECOND VISIT
If with symptom improvement within 1 week, complete the prescribed antibiotic regimen (AI)
If with no improvement or if with worsening of symptoms despite adherence or if with adverse reactions to the previously
prescribed antibiotics, offer change in antibiotics (AII)
If no improvement or worsening of symptoms because of poor adherence, continue the first antibiotic prescribed and complete
the prescribed regimen (AIII)
Non-pharmacologic Intervention
Advise increase oral fluid intake for adequate hydration and soft diet (AIII) for patients with odynophagia and consider home
remedies such as salt-water gargles (AII)
Consider offering chlorhexidine plus benzydamine combination throat spray (AI), if available or chlorhexidine or benzydamine
oral spray for symptomatic relief (AII)
Educate regarding possible etiologies of acute pharyngitis, transmission, and complications of Streptococcal pharyngitis (AIII)
Educate regarding the dose, frequency, possible adverse effects of medications and the importance of completing the prescribed
antibiotic regimen (AII)
To reduce transmission, educate regarding cough and sneeze etiquette and hand hygiene and advise to stay home until afebrile
and/or completion of ≥ 24 hours of appropriate antibiotic therapy (AIII)
Educate the family regarding possible etiologies of acute pharyngitis, transmission, treatment and complications of Streptococcal
pharyngitis (AIII)
Explore and educate on exposure to possible irritants in the community and the workplace (AIII)
SECOND VISIT
If symptoms are still present, reinforce advice on use of supportive treatment and home remedies for symptomatic relief (AII)
Reinforce health education regarding possible complications and treatment of Streptococcal pharyngitis (AIII)
Reinforce education on hand hygiene and cough and sneeze etiquette to reduce transmission (AIII)
Reinforce education on the proper dosage and intake of antibiotics (AII) and provide counseling on adherence to medications (AII)
Reinforce health education regarding transmission, treatment and possible complications of Streptococcal pharyngitis (AIII)
Reinforce advice on avoidance of exposure to possible irritants in the community and the workplace (AIII)
Patient Outcomes
Receives information about acute tonsillopharyngitis – possible etiologies and complications and agrees with pharmacologic
and non-pharmacologic treatment plan (AIII)
Aware of the dose, frequency, indications and side effects of the medications given (AII)
Aware of the importance of compliance with antibiotic treatment and follow-up (AII)
Advise patient to follow-up after 7 days to assess for improvement or at any time if with worsening of symptoms (AII)
Symptom improvement or resolution (AII)
VOL. 59 NO. 2 DECEMBER, 2021 199
Implementation: Implementation of the clinical pathway will be at the practice and the organizational levels. The pathway may
be used as a checklist to guide family medicine specialists or general practitioners in individual clinic and community medicine
practice. It may also be used as reference for exams by the training programs and the specialty board. In the commitment to
achieve the goal of improving the effectiveness, efficiency and quality of patient care in family and community practice, the
clinical pathway may also be implemented through quality improvement activities in the form of patient record reviews, audit
and feedback. Audit standards will be the assessment and intervention recommendations in the clinical pathway. Organizational
outcomes can be activities of the PAFP devoted to the promotion, development, dissemination and implementation of clinical
pathways.
Introduction
Acute sore throat is a symptom caused by tonsillopharyngitis, an
acute inflammatory process of the pharynx and the tonsillar tissues. It
occurs more commonly in school-aged children, but patients of any age
can be affected. Acute sore throat is self-limiting and often triggered by
upper respiratory tract infection commonly caused by viruses such as
adenovirus, influenza virus, parainfluenza virus. Adults get two to four
upper respiratory tract infections every year, while children get six to
eight episodes. Symptoms can last around one week, but most people
will get better within this time without antibiotics, regardless of cause.1
Pharyngitis accounts for almost 10% of visits by children to outpatient
clinics.2 In a family-based cohort study, 41% of the children and 16%
of adults reported experiencing sore throat during the 16-month study
period.3
Group A-beta Hemolytic Streptococcus (GAS) is the most common
cause of bacterial pharyngitis, primarily affecting children 5 to 15
years of age. It accounts for 5-15% of throat visits in adults and 2030% in children.4 In children less than 3 years old, the prevalence of
tonsillophrayngitis caused by GAS is 10-14%.5 A small locally conducted
study found a 14.6% prevalence of GAS infection among patients
3 years old and above presenting with acute tonsillophrayngitis.6
Prevalence of Group C beta-hemolytic Streptococci infection among
uncomplicated acute sore throat is 3.15% in children and 11% in
adults. In addition, groups G b-haemolytic streptococci, Mycoplasma
pneumoniae, and Chlamydia pneumoniae have been mentioned as
pathogens.7 Streptococcal pharyngitis is most commonly spread
through direct person-to-person transmission through saliva or nasal
secretions from an infected person. Crowded conditions such as those in
schools and daycare centers facilitate transmission. It is unlikely to be
spread through fomites such as household items.8
In the primary care setting, pharyngitis is the third among the
top diagnoses associated with antibiotic prescription (43 antibiotic
prescriptions per 1000 population [95% CI, 38-49]). Despite the
majority of cases being viral in origin, 50- 70% of patients from across
all age groups, consulting at ambulatory care clinics due to pharyngitis
are given antibiotics.9 Inappropriate antibiotic use leads to antibiotic
resistance, unnecessary cost for the patients and increase in adverse
events.
Untreated streptococcal pharyngitis may lead to suppurative
complications which include but are not limited to peritonsillar
abscess and other deep neck infections, endocarditis, meningitis
and mastoiditis.10 Non-suppurative consequences of streptococcal
200
pharyngitis, which are uncommon, include acute rheumatic fever
and acute glomerulonephritis. Antibiotic treatment may be indicated
for GAS infection to prevent suppurative complications and acute
rheumatic fever and to reduce the duration of symptoms and the
spread of the infection. Recurrent streptococcal tonsillopharyngitis
defined as documented recurrent pharyngeal infections at a frequency
of 7 episodes in one year, five episodes per year for two years, three
episodes per year for three years or recurrent infections, if accompanied
by any modifying risk factor such as a history of peritonsillar abscess or
multiple antibiotic allergies is an indication for tonsillectomy.11
This clinical pathway is an update of the clinical practice guidelines
developed and published in 2010. The recommendations focus on the
diagnosis and treatment of uncomplicated tonsillophrayngitis with
duration of symptoms of 14 days in adults and children in the primary
care setting. It does not cover the evaluation and management of
recurrent or persistent cases of sore throat, complicated pharyngitis
such as peritonsillar abscesses, epiglottitis, submandibular and
retropharyngeal space infections, and cases of immunosuppression,
or history of acute rheumatic fever and COVID-19-related
tonsillopharyngitis. Primary outcome considered is symptom relief or
clinical cure. For cases of tonsillopharyngitis beyond the scope of this
guideline, management may be done based on the appropriate clinical
judgment of the family physician.
Objective
This clinical pathway was developed to guide family and
community physicians on the diagnosis and management of acute
tonsillopharyngitis. It provides recommendations to the following
clinical decisions: 1) clinical history and physical examination;
2) laboratory and ancillary procedures to be requested; 3) pharmacologic
interventions; 4) non-pharmacologic interventions; and 5) patient
outcomes to expect.
Methods of Development and Implementation
The development of this clinical pathway followed the 8-step
approach developed by the PAFP Research Committee. The research
committee first identified volunteers to be the members of the Clinical
Pathways Development Group (CPDG). They were screened for their
expertise and experience in family and community medicine. The CPDG
discussed and defined the scope of the clinical pathway and identified
THE FILIPINO FAMILY PHYSICIAN
the key issues for decision making in managing patients with acute
tonsillopharyngitis.
The key issues were then translated into review questions. The
review questions identified were similar to the other clinical pathways
previously developed by the academy i.e., how the patients with sore
throat should be evaluated, what diagnostic test to request, what
drug to prescribe, what non-pharmacologic interventions to give and
what should be the expected patient outcomes. Based on these review
questions, the group searched, reviewed and summarized the evidence
from clinical practice guidelines, systematic reviews and meta-analysis,
randomized trials and observational studies.
For the fourth step, the PAFP Clinical Pathways Group reviewed the
published medical literature to identify, summarize, and operationalize
the evidence in clinical publication on the management of patients
with acute tonsillopharyngitis in family and community practice. The
authors searched for the latest guidelines from reputable societies such
as Infectious Disease Society of America (IDSA), European Society for
Clinical Microbiology and Infectious Diseases (ESCMID) and National
Institute for Health and Care Excellence (NICE) and appraised each using
the AGREE II checklist. They also searched PubMed and Herdin using the
terms “tonsillopharyngitis” or “tonsillitis”, “diagnosis” and “treatment”.
Retrieval of articles was focused on the following type of clinical
publications clinical trials, meta-analysis and observational studies.
The more rigorous meta-analysis of clinical trials and observational
studies were prioritized over low quality trials in the formulation of
the recommendations. The evidence for the patient care processes were
reviewed and summarized as notes to justify the recommendations. To
assess the quality of evidence, the CPDG utilized the modified GRADE
approach.
From the evidence-based summaries, the CPDG then developed
general guideline and pathway recommendations for the management
of acute tonsillopharyngitis in family practice. These recommendations
are patient-centered, putting emphasis on the involvement of the
patient in decisions on diagnosis and treatment. Recommendations
are time-bound tasks on patient care processes, in terms of history
and physical examination, laboratory tests, pharmacologic and nonpharmacologic interventions
The sixth step was to present the recommendations to a panel of
experts and discuss potential variations in different settings of family
practice. The CPDG recommendations were presented to a panel of
family and community practitioners in both urban and rural settings,
for a consensus agreement on the applicability of the recommendations
to family and community practice. The panel voted on each
recommendation if each should be adopted for the whole country.
Step 7 was to write the final clinical pathway which should include
the recommendations, the clinical pathway tables and an algorithm.
The clinical pathway can be used as a checklist or standards of care. The
algorithm can be used to explain the process of care to the patient.
For the last step, the clinical pathway will then be disseminated to
the different PAFP chapters and members in the form of publication in
the Filipino Family Physician Journal, through conference presentations
during the PAFP Annual Convention and focused group discussions
with chapter members. Implementation of the clinical pathway will
be at the practice level and the organizational level. The pathway may
VOL. 59 NO. 2 DECEMBER, 2021 be used as a checklist to guide family medicine specialists in practice.
It may also be used as reference for exams by the training programs
and the specialty board. In the commitment to achieve the goal of
improving the effectiveness, efficiency, and quality of patient care
in family and community practice, the clinical pathway may also be
implemented through quality improvement activities in the form of
patient record reviews, audit and feedback. Audit standards will be the
assessment and intervention recommendations in the clinical pathway.
Organizational outcomes can be activities of the PAFP devoted to the
promotion, development, dissemination and implementation of clinical
pathways.
Grading of the Recommendations
The consensus panel composed of family medicine practitioners
from different settings, met and graded the recommendations as shown
in Table 1. The grading system was a mix of the strength of the reviewed
published evidence and the consensus of a panel of experts. In some
cases, the published evidence may not be applicable in the Philippine
family and community practice setting, so a panel grade based on the
consensus of clinical experts was also used. Thus, if the recommendation
was based on published evidence that is a well done randomized
controlled trial and the panel of experts voted unanimously for the
recommendation, it was given a grade of A-I. If the level of evidence
is based on an observational study but the panel still unanimously
considered the recommendation, the grade given was A-II and if the
level of evidence is just an opinion and the panel still unanimously
recommended it, the grade was A-III.
Table 1. Grading of the recommendations.
Panel Grade LevelEvidence Grade Level
1 2 3
AA-IA-IIA-III
BB-IB-IIB-III
CC-IC-IIC-III
Panel Grade Levels
A - All the panel members agree that the recommendation should be
adopted because it is relevant, applicable and will benefit many
patients.
B - Majority of the panel members agree that the recommendation
should be adopted because it is relevant, applicable in many areas
and will benefit many patients.
C - Panel members were divided that the recommendation should be
adopted and is not sure if it will be applicable in many areas or will
benefit many patients.
Evidence Grade Levels
I - The best evidence cited to support the recommendation is a wellconducted randomized controlled trial. The CONSORT standard may
be used to evaluate a well-conducted randomized controlled trial.
II - The best evidence cited to support the recommendation is a wellconducted observational study i.e. matched control or before and
201
after clinical trial, cohort studies, case control studies and crosssectional studies. The STROBE statement may be used to evaluate
a well-conducted observational study.
III - The best evidence cited to support the recommendation is based
on expert opinion or observational study that did not meet the
criteria for level II.
In the implementation of the clinical pathways, the PAFP QA
committee recommends adherence to guideline recommendations
that are graded as either A-I, A-II or B-I. However, the committee also
recommends using sound clinical judgment and patient involvement in
the decision making before applying the recommendation.
Pathway Recommendations
Pathway Tasks
Visit
History and Physical Examination
First Visit
For ALL patients presenting with
acute sore throat:
Diagnostic Tests
__Offer rapid antigen test for
Streptococcal infection to patients
3 years of age and older with
__ Elicit history of throat pain
Centor score of ≥3, if available
and its intensity, fever and painful (CII)
lymph nodes on the neck and
duration of symptoms. (AII)
__Elicit history of recurrent
tonsillopharyngitis and
peritonsillar abscess and drug
allergies (AII)
__Evaluate socioeconomic status
(BII)
__Examine for fever, tonsillar
swelling, exudates, and cervical
lymphadenitis. (AII)
__Examine for signs of
dehydration (BIII)
__Obtain the Centor or FeverPAIN
score to determine probability of
streptococcal infection (AII)
Pharmacologic Intervention
Non-pharmacologic Intervention
Patient Outcomes
__Offer symptomatic
treatment with paracetamol
or NSAID in lozenge or oral
form. (AI)
Patient Intervention
__ Advise increase oral fluid intake
for adequate hydration and soft diet
for (AIII) patients with odynophagia
and consider home remedies such as
salt-water gargles (AII)
__ Receives
information
about acute
tonsillopharyngitis
– possible etiologies
and complications
and agrees with
pharmacologic and
non-pharmacologic
treatment plan (AIII)
__In adult patients with more
severe presentations e.g Centor
score 3-4 , consider offering a __Consider offering chlorhexidine
single low-dose corticosteroid plus benzydamine combination
throat spray, if available (AI) or
(AI)
chlorhexidine or benzydamine oral
__Antibiotics should only be spray (AII) for symptomatic relief
offered if the rapid antigen
__Educate regarding possible
test is positive or if Centor
score is ≥3 or FeverPAIN score etiologies of acute pharyngitis,
is ≥4. Penicillin or Amoxicillin transmission, and complications of
is given as first-line antibiotic Streptococcal pharyngitis (AIII)
treatment. Cephalosporins and
macrolides are given in case of __Educate regarding the dose,
frequency, possible adverse effects
allergies to penicillin (AI)
of medications and the importance
of completing the prescribed
antibiotic regimen (AII)
For patients with FeverPAIN
score 2-3, consider offering a
back-up antibiotic prescription __ To reduce transmission, educate
if symptoms deteriorate rapidly regarding cough and sneeze
etiquette and hand hygiene and
or significantly, or do not
advise to stay home until afebrile
improve within 3 to 5 days
and/or completion of ≥ 24 hours of
appropriate antibiotic therapy. (AIII)
__Aware of the dose,
frequency, indications
and side effects of the
medications given (AII)
__ Aware of the
importance of
compliance with
antibiotic treatment
and follow-up (AII)
Follow-up Visit
__Advise patient
to follow-up after
7 days to assess for
improvement or at any
time if with worsening
of symptoms (AII)
Family Intervention
__Educate the family regarding
possible etiologies of acute
pharyngitis, transmission, treatment
and complications of Streptococcal
pharyngitis (AIII)
Community-level Intervention
__Explore and educate on
exposure to possible irritants in the
community and the workplace (AIII)
Variation
202
Discuss referral to specialist and
the possibility of tonsillectomy if
with recurrent tonsillopharyngitis
Understands
when referral for
tonsillectomy is
necessary
THE FILIPINO FAMILY PHYSICIAN
Pathway Tasks
Pharmacologic Intervention
Non-pharmacologic Intervention
__Re-evaluate the presence of
__Offer throat swab and culture
throat pain and its intensity, fever, if initial antibiotic treatment
tonsillopharyngeal congestion,
fails (AII)
and tonsillar exudates (AII)
__ If with symptom
improvement within 1 week,
complete the prescribed
antibiotic regimen (AI)
Patient Intervention
__If symptoms are still present,
reinforce advice on use of supportive
treatment and home remedies for
symptomatic relief (AII)
__ Assess adherence to treatment
(AII) and explore reasons for nonadherence (AIII)
__If with no improvement
or if with worsening of
symptoms despite adherence
or if with adverse reactions
to the previously prescribed
antibiotics, offer change in
antibiotics (AII)
Visit
History and Physical Examination
Second Visit
Diagnostic Tests
__ Ask for presence of any adverse
drug event (AIII)
__ Examine for signs of
suppurative complications if with
no improvement in symptoms (AII)
__If no improvement or
worsening of symptoms
because of poor adherence,
continue the first antibiotic
prescribed and complete the
prescribed regimen. (AIII)
__Reinforce health education
regarding possible complications
and treatment of Streptococcal
pharyngitis (AIII)
__Reinforce education on hand
hygiene and cough and sneeze
etiquette to reduce transmission
(AIII)
__Reinforce education on the
proper dosage and intake of
antibiotics (AII) and provide
counseling on adherence to
medications (AII)
Patient Outcomes
__Symptom
improvement or
resolution (AII)
__For non-improving
cases and antibiotic
was changed or
shifted, patient agrees
with new antibiotic
treatment and
understands its dose,
frequency, indication
and possible side
effects (AII)
__Aware of the
diagnostic test if any
will be conducted, its
benefit and harm (AIII)
Family Intervention
__Reinforce health education
regarding transmission, treatment
and possible complications of
Streptococcal pharyngitis (AIII)
Community-level Intervention
__Reinforce advice on avoidance of
exposure to possible irritants in the
community and the workplace (AIII)
Variation
Discuss the possibility of referral
to specialist if there is failure of
treatment or signs of suppurative
complications despite adequate
adherence to treatment.
Clinical Evidence of the Recommendations
Understands
when referral for
tonsillectomy is
necessary
Recommendation 1. Elicit history of throat pain and its intensity, fever,
and painful lymph nodes on the neck and duration of symptoms (AII)
First Visit
Clinical History and Physical Examination
Because of the risk of developing complications among untreated
Streptococcal throat infections, it is important to identify those needing
antibiotic therapy for such infection. However, it is often difficult to
distinguish throat infections of bacterial from those of viral etiology.
Rapid antigen testing has low sensitivity and accurate tests like culture
takes longer. Although most symptoms of bacterial overlap with those
of viral tonsillopharyngitis, a few are found to be more associated with
streptococcal infection.
VOL. 59 NO. 2 DECEMBER, 2021 Streptococcal pharyngitis generally presents with acute-onset
sore throat, pain on swallowing, painful cervical lymph nodes and
fever. Absence of fever or the presence of cough, coryza or conjunctivitis
suggests a viral rather than a streptococcal etiology. 4,12 In a prospective
study among adults (n 179) with symptoms of acute pharyngitis, fever
OR 1.5, 95% CI 0.7 to 3.1) and absence of cough (OR 0.9, 95% CI 0.4
to 2.1) were more likely associated with streptococcal infection. 13
Children may also present with nausea, vomiting and abdominal
pain.4 In a systematic review of observational studies, vomiting was
moderately associated with streptococcal pharyngitis (LR, 1.79; 95%
CI, 1.58-2.16).2
203
Recommendation 2. Elicit history of recurrent tonsillopharyngitis,
peritonsillar abscess and drug allergies (AII)
Recurrent streptococcal tonsillopharyngitis may require antibiotic
treatment to prevent rheumatic fever, suppurative complications, and
shorten the symptoms. Watchful waiting is strongly recommended for
recurrent throat infections <7 episodes in the past year, <5 episodes
per year in the past 2 years, or <3 episodes per year in the past 3
years. Family physicians should assess history of multiple antibiotic
allergies and >1 peritonsillar abscess in children with recurrent
tonsillopharyngitis. Tonsillectomy is indicated in children with recurrent
infections and with any of these modifying factors.14 This was adopted
from the 2019 American Academy of Otolaryngology-Head and Neck
Surgery Guidelines. The recommendation was based on observational
studies. Referral to specialist for possible tonsillectomy should be
discussed if these parameters are present. Presence of allergies to
specific medications also need to be considered when deciding on
which pharmacologic therapy will be offered.
Recommendation 3. Evaluate socioeconomic status (BII)
As streptococcal pharyngitis is commonly spread through personto-person contact, low socioeconomic status depicted by overcrowding
and improper hygienic practices and in addition, environmental
pollution, cause an increase in transmission of the disease. In a local
study, there was a high incidence of acute tonsillopharyngitis caused by
streptococcus among patient consulting at a government clinic (whose
patients usually belong to the lower socioeconomic group) as compared
to patients consulting at a private clinic.15 Recent studies have also
shown that Vitamin D deficiency might be associated with an increase
in the risk of recurrent tonsillopharyngitis.16 Socioeconomic status may
also affect nutrition and Vit D levels.17
Recommendation 4. Examine for fever, tonsillar swelling, exudates, and
cervical lymphadenitis (AII)
On physical exam, clinical practice guidelines recommend taking
note of signs that are associated streptococcal throat infection including
presence of fever, tonsillopharyngeal congestion, presence of tonsillar
exudates and tender cervical lymph nodes.1,4,18 In a prospective study
among adults (n 179) with symptoms of acute pharyngitis, presence of
tonsillar exudates correlated best with GAS (odds ratio [OR] 2.4, 95%
CI 1.1 to 5.0) followed by a history of fever (OR 1.9, 95% CI 0.9 to 4.1)
and cervical adenopathy (OR 1.5, 95% CI 0.7 to 3.1).12 In this study, the
distribution of symptoms was compared between those having bacterial
etiology and non-bacterial etiology based on throat culture and ASO
titer. The diagnosis of Streptococcal pharyngitis seemed probable if the
findings of sore throat, pharyngeal congestion and enlarged tonsils
are accompanied by any or a combination of cervical adenitis, fever
and leukocytosis. Other symptoms like cough and rhinorrhea were not
significantly associated with Streptococcal infection.
In children, the presence of scarlatiniform rash, palatal petechiae,
pharyngeal exudate, vomiting, and tender cervical nodes in combination
increase the likelihood of GAS to greater than 50%.19 A systematic
204
review of 38 articles wherein diagnosis of Streptococcal pharyngitis was
made using throat culture and positive rapid antigen tests, showed that
the presence of a scarlatiniform rash (likelihood ratio [LR], 3.91; 95%
CI, 2.00-7.62), palatal petechiae (LR, 2.69; CI, 1.92-3.77), pharyngeal
exudates (LR, 1.85; CI,1.58-2.16), vomiting (LR, 1.79; CI, 1.58-2.16), and
tender cervical nodes (LR, 1.72; CI, 1.54-1.93) were moderately useful
in identifying those with streptococcal pharyngitis.2 In another local
study among children, sore throat, fever, pharyngeal congestion, age,
headache, cervical adenitis, month of illness, cough and white blood
cell count have been included as parameters tested for the diagnosis of
streptococcal throat infection.15 In this study, a clinical scoring system
that included the said clinical parameters was compared with Strep A
test in terms of accuracy in detecting streptococcal throat infection. The
sensitivity and specificity of the clinical scoring was comparable with
the Strep A test with culture as the reference standard for diagnosis (Sn
87.5% vs 88%, respectively and Sp 91% vs 90%, respectively).
Recommendation 5. Examine for signs of dehydration (BIII)
Oral intake is limited with acute pharyngitis especially if
accompanied by significant pain on swallowing. Proper oral hydration
as supportive treatment is advised.20
Recommendation 6. Obtain the Centor or FeverPAIN score to determine
probability of streptococcal infection (AII)
Clinical scoring systems have been developed and are helpful in
determining patients’ risk of having streptococcal infection. Clinical
prediction rules can be used to make the decision whether to initiate
empirical antibiotherapy only if diagnostic tests are not available or in
patients at risk of developing rheumatic fever.5 These scoring systems
can also be used to monitor disease severity and guide decision making
for the antimicrobial treatment.21
In 1981, the Centor scoring was developed based on the evaluation
of 234 patients >15 years of age presenting at the Emergency Room
complaining with sore throat. In this cross-sectional study, the presence
of tonsillar exudates was found to be the best predictor for a positive
culture for Group A streptococcus, followed by anterior cervical adenitis,
fever and lack of cough. The predictive model for positive culture using
these 4 clinical parameters as variables is shown in table 1.22
Table 1. Predictive Model for Positive Culture, Centor, et al, 1981.
Number of variables present Probability of Positive Culture
455.7%
330.1 - 34.1%
214.1 - 16.6%
1 6.0 - 6.9%
0 2.5%
THE FILIPINO FAMILY PHYSICIAN
The Centor clinical scoring system (table 2) can help to identify
those patients who have a higher likelihood of group A streptococcal
infection. A Centor score of 3 or greater is associated with a probability
of streptococcal aetiology of 30% to 56%.18
Table 2. Centor scoring system, ESCMID, 2012.
guide antimicrobial treatment, with similar outcome as with the use
of rapid antigen testing. Targeted use of the FeverPAIN clinical scoring
system improved symptoms on days 2 to 4 and reduced antibiotic
use. The additional use of rapid antigen tests for GAS pharyngitis in
people with a high FeverPAIN score had no clear advantage over using
FeverPAIN score alone.24
Signs and Symptoms Score
Temperature > 38 degrees Celsius1
No cough1
Tender anterior cervical lymphadenopathy1
Tonsillar swelling or exudate1
This was later modified by adding age and was validated in about
600 adults and children (3–15 years old) in 1998 in a Canadian study and
later again in 2004 (Table 3).23 In this study, use of this modified Centor
criteria was elucidated in terms of management for acute sore throat
(Figure 1). In children less than 3 years old, the classic manifestations
i.e. exudative pharyngitis and incidence of streptococcal pharyngitis
are uncommon. This limits the use of clinical scoring in this age group.
Acute rheumatic fever is also rare in this age group thus, diagnostic
studies for GAS are not indicated. The risk of first attack ARF is likewise
low among adults even with an untreated episode of GAS pharyngitis.4
Table 3. Modified centor scoring (McIssac), ESCMID, 2012.
Signs and Symptoms Score
Figure 1. From McIsaac W, et al. Can Med Assoc J 1998
Temperature > 38 degrees Celsius1
No cough1
Tender anterior cervical lymphadenopathy1
Tonsillar exudate1
Table 4. Fever pain scoring, NICE, 2018.
Age
3 -14 years1
15 - 44 years0
> 44 years -1
Total Score Score
In a more recent clinical trial to guide antibiotic prescription,
symptom onset of ≤ 3 days was added to fever during the previous 24
hours , purulence, acute onset, inflamed tonsils, and absence of cough
or coryza in a clinical scoring system (FeverPAIN, Table 4) and used to
Symptom onset ≤ 3 days1
Fever during the previous 24 hours1
Purulence1
Severely inflamed tonsils1
No cough or coryza1
Table 5. Clinical scoring systems and corresponding risk of grp A Strep infection, ESCMID, 2012.
Centor Risk of group A streptococcal infection Modified Centor Score Risk of group A streptococcal infection FeverPAIN Score Risk of group A streptococcal infection
Score (%) (%) (%)
438-63>4 51-53 4 or 562 - 65
327-28 3 28-35 2 or 334 - 40
210-12 2 11-17 0 or 113 - 18
1 4-6 1 5-10
0 2-3 0 1-2.5
VOL. 59 NO. 2 DECEMBER, 2021 205
Table 5 shows the different clinical scoring systems and the
corresponding probabilities of streptococcal throat infection. In family
practice where the microbiologic identification of the etiologic agent is
not available or prohibitive in cost, the use of these clinical parameters
for decision making increases the probability of arriving at a correct
diagnosis and eventually treatment. The distinction between nonstreptococcal and streptococcal pharyngitis based on clinical parameters
alone may need to be done.25 This classification will therefore be of
value in deciding what treatment to give to the patient.
Diagnostic Tests
Recommendation 7. Offer rapid antigen test for Streptococcal infection
to patients 3 years of age and older with Centor score of ≥3, if available
(CII)
Acute tonsillopharyngitis is commonly caused by viruses or
bacteria. The most common bacterial etiology is group A streptococcus.
The highest prevalence of tonsillopharyngitis was noted during the
months of October to November, with the yield rate of streptococcus
from throat culture at around 25%.20 Throat swab culture is the
conventional method in establishing the etiologic diagnosis of acute
tonsillopharyngitis. But recent study showed that certain parts of oral
cavity swab can also be used.26 A positive throat culture for GABHS makes
the diagnosis of streptococcal sore throat likely but a negative culture
does not rule out the diagnosis. Because the growth must be observed
for a minimum of 48 hours, there is usually a delay in the administration
of treatment. In addition, symptoms also correlate poorly with results
of throat swab culture. Thus, throat swabs should not be carried out
routinely in primary care management of sore throat.27 Throat swabs
may be used to establish etiology of recurrent severe episodes in adults
when considering referral for tonsillectomy.
An alternative is the use of a rapid antigen test (RAT) that can
be done as an office procedure. Use of RAT is considered in patients
with high likelihood of streptococcal infections (Centor score of 3-4).22
Compared to clinical scoring, rapid antigen tests are more sensitive in
detecting streptococcal infections. In a cross-sectional study among 520
pediatric patients with throat swab culture as the reference standard,
the RAT’s sensitivity, specificity, PPV and NPV were 86.1%, 97.1%,
93.7 % and 93.4% respectively.28 In another cross-sectional study
among patients 4 years old and above, RAT detected an additional
50% of patients with strep throat compared to clinical assessment.29
In a prospective study locally conducted to determine the accuracy of
rapid antigen tests in detecting GAS infection among patients 3 years
of age and older presenting with acute tonsillopharyngitis, the positive
predictive value ranged from 52.9 - 73.7% depending on which brand
of test kit and the negative predictive value was almost 99%.6
One strategy to guide antibiotic prescription is to use rapid tests
for group A streptococcus alone or in combination with clinical scoring.
In a systematic review of randomized controlled trials, there was a large
reduction (25%) in prescribed antibiotics when rapid antigen test was
used to guide treatment. However, rapid tests did not significantly
reduce actual dispensed antibiotic treatment: rapid test group
(156/445) versus management based on clinical grounds (197/455)
206
(summary Risk Difference −7%, 95% CI −17% to 2%; I2 = 53%).30 In
a large randomized controlled trial involving patients aged 3 years old
and above (n 1107) with acute sore throat, targeted use of antibiotics
with the FeverPAIN scoring improved symptoms and reduced antibiotic
use by 29%. Use of antigen tests provided similar benefits (reduction of
antibiotic use by 27%) but no clear advantage over use of the scoring
system.24
IDSA recommends rapid antigen detection test to diagnose
Streptococcal acute tonsillopharyngitis. It emphasized that clinical
features alone do not reliably discriminate between Streptococcal
and viral pharyngitis.4 However, it recommends against testing in
children and adults with clinical features that strongly suggest viral
etiology. ESCMID recommends to consider use of rapid antigen tests
only in patients with high likelihood of streptococcal throat infection
e.g. Centor score of 3-4. IDSA recommends for negative RAT tests to
be backed up by a throat culture in children and adolescents. ESCMID
recommends otherwise. If RAT is performed, throat culture is not
necessary after a negative RAT for the diagnosis of group A streptococci
in both children and adults.18 Positive RADTs do not necessitate a backup culture because they are highly specific.4
Pharmacologic Interventions
Recommendation 8. Offer symptomatic treatment with paracetamol or
NSAID in lozenge or oral form. (AI)
The first line of treatment for acute tonsillopharyngitis is
symptomatic relief. For fever and pain, oral paracetamol or NSAID
can be given.4 After two days of regular dosing, paracetamol appears
to successfully alleviate the pain of acute infective sore throat. Nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the pain of sore
throat in 2 to 5 days.31
Newer delivery system in the form of lozenge is also available for
some NSAID (flurbiprofen 8.75 mg lozenges) and may provide faster
onset of action. In a randomized controlled trial of 204 patients with
confirmed pharyngitis, patients treated with flurbiprofen lozenges
reported significantly greater reductions in sore throat pain (47%) as
well as difficulty swallowing (66%) and swollen throat (40%) compared
with placebo (all p < 0.05).32 In another randomized controlled trial
where “swollen” and “inflamed” throat were considered the most
bothersome, patients who received flurbiprofen 8.75 mg had greater
relief than placebo over 24 hours: 79.8%, 99.6% and 69.3% (for sore
throat pain, difficulty swallowing and swollen throat, respectively,
all p ≤ 0.01). These outcomes were more substantial in patients with
relatively severe symptoms.33
Another lozenge preparation that contains fixed-combination of
0.5 mg tyrothricin, 1.0 mg benzalkonium chloride, and 1.5 mg benzocaine
has also been compared to placebo in a randomized controlled trial.
However, significant relief was noted only after 72 hours with complete
resolution of throat pain and difficulty in swallowing achieved by 44.6%
patients on the study drug compared with 27.2% patients on placebo.34
Medicated throat lozenges and topical anesthetics can help with throat
pain, but patients must use them regularly every 2 hours to see results.35
Adults can use topical anesthetics containing benzocaine, but children
THE FILIPINO FAMILY PHYSICIAN
should avoid them since they can cause methemoglobinemia.36 Chinese
herbal medicines, on the other hand, are not beneficial for sore throat,
according to a 2010 Cochrane review of seven low-quality trials with
1,253 individuals.37
Recommendation 10. Antibiotics should only be offered if the rapid
antigen test is positive or if Centor score is ≥3 or FeverPAIN score is ≥4.
Penicillin is given as first-line antibiotic treatment. Cephalosporins and
macrolides are given in case of allergies to penicillin (AI)
Recommendation 9. Offer single low dose corticosteroid to adult
patients with severe sore throat e.g Centor score 3-4 or FeverPAIN score
of 4-5 (AI)
The second line treatment is antibiotics. Antibiotic treatment
specifically with Penicillin was not more beneficial than placebo in
resolving symptoms of sore throat even in children with group A
streptococci in a randomized controlled trial. However, penicillin may
reduce streptococcal sequelae.41 ESCMID recommends that antibiotic
treatment be considered only for more severe presentation of sore
throat e.g. Centor score 3 or 4. The modest benefits of antibiotics
must be balanced against side effects, the effect of antibiotics on
the microbiota, increased antibacterial resistance, and costs.1,I8 NICE
recommends antibiotic treatment for patients with FeverPAIN score of
4 or 5.1 IDSA, on the other hand, recommends antibiotic treatment for
those with GAS pharyngitis diagnosed based on positive RADT of throat
swab.4
IDSA recommends Penicillin or Amoxicillin as drug of choice for
antibiotic treatment of streptococcal pharyngitis due to its narrow
spectrum, modest cost, proven efficacy and infrequency of adverse
reactions.4 Likewise, ESCMID also recommends Penicillin as the firstline treatment. Amoxicillin is preferred in children because of its taste
and availability in syrup and suspension.18 A more recent guideline from
Spain (2020) on treatment of streptococcal pharyngitis in children still
recommends Penicillin or Amoxicillin.5
A Cochrane network meta-analysis of all antibiotics used for acute
tonsillopharyngitis conducted recently included 19 trials involving
5,839 participants with most trials conducted in the outpatient
setting of high income countries. No difference in effectiveness,
adverse effects and relapse rates was found between cephalosporins,
penicillin, and macrolides.42 Thus, cephalosporins and macrolides may
be used as alternative for patients with allergies to Penicillin. A firstgeneration cephalosporin is an option for patients who have type
IV hypersensitivity reactions to penicillin (e.g., rash). Clindamycin,
clarithromycin, or azithromycin should be given to patients who have
type I hypersensitivity responses (anaphylaxis).4
Existing guidelines recommend a 10-day duration for both
Penicillin and Amoxicillin is for maximum eradication of GAS and to
prevent of rheumatic fever.4,6,18 Shorter duration of new generation
antibiotics may have comparable efficacy to standard duration
penicillin. In a meta-analysis of 20 studies with 13,102 patients, the
short duration treatment with new generation antibiotics had shorter
periods of fever (MD-0.30 days, 95% CI-0.45 to -0.14) and sore throat
(MD -0.50 days, 95% CI -0.78 to -0.22). However, the risk of late
bacteriological recurrence was worse in the short duration treatment
except with low dose azithromycin (10 mg/kg). This Cochrane review
from 2012 indicated that a three- to six-day course of antibiotics and
a 10-day course of antibiotics had equivalent effectiveness. When the
frequency of rheumatic fever is low and the sole goal of treatment is
symptom relief, a shorter course of antibiotics may be an alternative.
The American Academy of Pediatrics, the American College of Physicians,
and the IDSA all recommend prescribing a 10-day course of penicillin in
locations where rheumatic fever is more common.43
Single low dose corticosteroids can also provide pain relief
in patients with acute tonsillopharyngitis. In one meta-analysis
conducted in 2017 of 10 clinical trials that enrolled 1,426 individuals,
those who received single low dose corticosteroids (e.g. dexamethasone
max of 10mg given orally in 5 studies and intramuscularly in 3 studies)
experienced pain relief twice as likely after 24 hours (RR 2.2, 95% CI 1.2
to 4.3) and 1.5 times more likely at 48 hours (RR 1.5, 1.3 to 1.8). The
mean time to onset of pain relief was 4.8 hours earlier (95% CI -1.9 to
-7.8) than placebo. Nine out of the 10 studies, sought data regarding
adverse events out of which 6 reported no adverse events and 3
reported few adverse events with similar incidence in both groups. In all
the 10 studies, corticosteroids was given as adjunct to standard of care.
Standard of care was analgesia and antibiotic (3 trials) or analgesia or
antibiotics alone (7 trials).38
In another meta-analysis conducted earlier in 2012 of 8 clinical trials
wherein both children and adults were included as participants, those
treated with corticosteroids (betamethasone 8mg, dexamethasone
10mg or prednisone 60mg) as adjunct to antibiotic therapy were three
times more likely to experience complete resolution of pain (risk ratio
(RR) 3.16, 95% confidence interval (CI) 1.97 to 5.08; p < 0.001; I2
statistic 44%) at 24 hours. The number needed to treat is 3. (95% CI
2.8 to 5.9). Subgroup analysis of oral versus intramuscular drug routes
revealed a significant benefit in both routes with a greater effect size
for the intramuscular route, although not statistically different from
the oral route (oral: RR 2.56, 95% CI 1.53 to 4.27; intramuscular: RR
4.68, 95% CI 2.08 to 10.52). Only two of the trials included children
and these trials had inconsistent results. In 7 of the studies, simple
analgesia was allowed but only 4 studies recorded analgesia use. 39
Mean time to onset of pain relief and complete resolution of pain were
reduced by 6 and 14 hours, respectively with intake of corticosteroid.
There was no difference in rates of recurrence of disease and adverse
events reported for participants taking corticosteroids compared to
placebo. Results from the 2 trials involving children were inconsistent,
thus no clinical benefits of corticosteroid intake were established
among children.
The above mentioned studies support the earlier findings that
corticosteroids shorten the duration of symptoms, but should not
be used routinely to treat symptoms of GABHS pharyngitis.40 ESCMID
recommends that use of corticosteroids can be considered in adult
patients with severe presentation (e.g. Centor criteria score of 3-4). No
evidence of significant benefit was found in children.18 Due to the selflimiting nature of the disease, concerns regarding safety and presence
of safer and effective alternatives, IDSA and NICE do not recommend
use of steroids as adjunct or stand alone therapy for the management of
acute tonsillopharyngitis.
VOL. 59 NO. 2 DECEMBER, 2021 207
The Department of
Health (DOH) also recommends
phenoxymethylpenicillin or Penicillin V as first-line and Amoxicillin
as second-line treatments for streptococcal pharyngitis or tonsillitis
and macrolides as alternative for patients with allergies to penicillin.44
Shown in Table 6 are the different antibiotics recommended by
guidelines for the treatment of streptococcal throat infection.
Non-pharmacologic Interventions
Back-up antibiotics
Recommendation 11. Advise increase oral fluid intake for adequate
hydration and soft diet (AIII) for patients with odynophagia and
consider home remedies such as salt-water gargles (AII)
The 2018 NICE guideline for antimicrobial prescribing in acute
sore throat recommends that a back-up antibiotic prescription may
be considered for patients who are assessed to have FeverPAIN score
of 2-3.1 This back-up antibiotic prescription must be used only if there
will be no observed improvement in symptoms within 3 to 5 days or
if symptoms worsen significantly at any time. Delayed antibioticprescription strategies were associated with reduced antibiotic use
when compared with an immediate strategy among patients with
uncomplicated respiratory infections (n = 405) in a pragmatic, openlabel randomized clinical trial.45
Patient Centered
The goal of non-pharmacologic intervention in acute pharyngitis
during the initial visit is relief of sore throat and discomfort.
Symptomatic non-pharmacologic treatment is recommended.
This includes rest while there is fever, warm water with salt gargle
(1/4 teaspoon of salt with 8 ounces of water) for relief of sore throat
and adequate intake of fluids.46,47 Despite the lack of evidence from
randomized controlled trials to prove benefit of increased oral fluid
intake in pharyngitis and upper respiratory infections48, guidelines
usually advise for adequate hydration.1 Other recommendations
include soft diet and cool beverages for patients with odynophagia.47
Table 6. Recommended antibiotics for the treatment of streptococcal throat infection.
First Line
Second Line
Adults
Adults
Phenoxymethylpenicillin or Penicillin V
500mg q12h or 250mg PO q6h on empty stomach x 10d (NICE / DOH)
Amoxicillin trihydrate 500mg PO q12h x 10d (DOH / IDSA)
OR
For penicillin allergy: The primary choice is a macrolide, such as: Erythromycin
ethylsuccinate 400mg PO q6-12h x 10d OR
Benzathine Penicillin G 1.2MU IM x 1dose (DOH)
Clarithromycin 250mg PO q12h x 10d OR
Azithromycin 500mg x 1 dose and then 250mg PO qd x 4d or 500mg PO qd x
3d-5d
First-generation cephalosporin (IDSA) Cephalexin 20 mg/kg PO (max. 500 mg/
dose) every 12 hours
Alternative to the macrolides for severe penicillin allergy: Clindamycin 300450mg PO q6-8h x 10d
Pediatrics
Phenoxymethylpenicillin or Penicillin V 25-50mg/kg/d PO q6h x 10d OR
Amoxicillin trihydrate 50mg/kg/d PO q8-12h (Max: 1g/d) x 10d
Amoxicillin trihydrate 50mg/kg/d PO q8-12h (Max: 1g/d) x 10d
For penicillin allergy: The primary choice is a macrolide, such as: Erythromycin
ethylsuccinate 40 mg/kg/d PO q6h (Max: 1g/d) x 10d OR Clarithromycin 15mg/
kg/d PO div q12h x 10d (NICE 7.5mk) OR Azithromycin 12 mg/kg (max 500mg)
PO qd x 5 days or 250mg PO qd x next 4d or 500mg PO qd x 3d-5d
Alternative to the macrolides for severe penicillin allergy: Clindamycin 20-30mg/
kg/d PO q8h (Max: 1.8g/d or 300mg/dose) x 10d
208
THE FILIPINO FAMILY PHYSICIAN
Salt-water mouth rinse is as effective as chlorhexidine in reducing
oral inflammation in a small randomized controlled trial.49 In a
randomized control trial involving 100 adult patients with acute nonbacterial pharyngitis (modified Centor score of 0 or 1), sodium chloride
3% mouthwash used at least 3 times a day for 1 week was more effective
than thymol glycerine in reducing VAS score of sore throat, difficulty in
swallowing and throat swelling. (mean change 3.92 vs 1.54, 3.92 vs
1.54 and 3.94 vs 1.58 respectively; p < 0.001).50
Recommendation 12. Consider offering chlorhexidine plus benzydamine
combination throat spray, if available (AI) or chlorhexidine or
benzydamine oral spray (AII) for symptomatic relief
Aside from lozenges, throat or oral sprays may also be advised.
Chlorhexidine plus benzydamine combination throat spray used 4x a
day was found to significantly reduce pain and improve clinical signs
and subjective state of health and quality of life by day 7 compared
with placebo in adults who were also taking phenoxymethylpenicillin,
based on high quality evidence from a randomized controlled trial
(n 147).51 In a prospective 2-arm study, lysozyme/cetylpyridinium/
lidocaine, chlorexhidine and benzydamine oral sprays significantly
reduce VAS scores of pain, difficulty in swallowing and throat swelling
in patients with acute tonsillopharyngitis and not on antibiotics or
analgesic.52
A systematic review of articles and guidelines was conducted in
2018 to determine clinical effectiveness of benzydamine 0.15% oral
rinse in acute sore throat. No relevant studies that examined the clinical
effectiveness of benzydamine oral rinse for pain relief in acute sore throat
were identified. One guideline that considered benzydamine as adjunct
therapy was identified but was not able to give recommendations on its
use due to insufficient evidence.53
Recommendation 13. Educate regarding possible etiologies of acute
pharyngitis and complications of Streptococcal pharyngitis (AIII)
Education regarding possible etiologies of acute pharyngitis
and complications of Streptococcal pharyngitis must be provided.
The family physician should ensure that patients with streptococcal
throat infection understand the medical course of their illness, possible
complications, and are satisfied with the assessment and treatment
plan.47
Recommendation 14. Educate regarding the dose, frequency, possible
adverse effects of medications and the importance of completing the
prescribed antibiotic regimen (AII)
While efforts in research on compliance are directed towards
shortening the course and decreasing the dose of treatment, efforts
about improving compliance through patient education are also
warranted. This can be done in the form of verbal or written patient
advice, discussion of possible complications and consequences of
poor compliance and asking for commitment. In a community-based,
open-labelled controlled trial, patient educational intervention
during medication dispensing regarding duration, dose, method
VOL. 59 NO. 2 DECEMBER, 2021 of use and correct compliance improved treatment adherence to
antibiotics. 54
Providing instructions via video may help as adjunct to improve
patient understanding. A prospective, randomized, controlled trial
done among adult patients with upper respiratory tract infection,
pharyngitis and gastroenteritis found a significant difference with
respect to discharge instructions knowledge in favor of the video
discharge instructions group versus those given standard discharge
procedures. Video discharge instructions, used as an adjunct to standard
verbal and written discharge methods, improved patient understanding
and retention of their discharge instructions.55
Recommendation 15. To reduce transmission, educate regarding cough
and sneeze etiquette and hand hygiene advise to stay home until
afebrile and/or completion of ≥ 24 hours of appropriate antibiotic
therapy. (AIII)
Since group A streptococcus is commonly spread through direct
person-to-person transmission via saliva and nasal secretions from
an infected person, it is important to advise patients regarding
good hand hygiene and respiratory etiquette. The Center for Disease
Control recommends for patients to stay home from work and school
until afebrile and completion of ≥ 24 hours of appropriate antibiotic
therapy.56
Family Intervention
Recommendation 16. Educate family regarding possible etiologies,
transmission, possible complications and treatment of acute pharyngitis
(AIII)
As in individual patient intervention, health education
regarding etiologies, transmission and complications of Streptococcal
pharyngitis (for pediatrics) may be offered to families of patients with
streptococcal throat infection. Information regarding strategies to
reduce transmission of streptococcus like hand hygiene and cough and
sneezing etiquette, must be provided. When prescribing medications
to children, educational materials may be given to parents to improve
their understanding regarding dosing, administration and possible side
effects. It is also important to discuss the diagnosis and benefits of
treatment.57
Community Intervention
Recommendation 17. Explore and educate on possible occupational
practices and exposure that could be triggers (AIII)
Interventions at the community level may include exploration
of possible exposure to smoke, outdoor pollution and irritants
in the neighborhood, community and the workplace. These
environmental factors which are considered as non-infectious
causes of sore throat may aggravate symptoms in patients with acute
tonsillopharyngitis. 58 Supportive treatment includes avoidance of
these irritants. 46
209
Patient Outcomes
Recommendation 18. Receives information about acute
tonsillopharyngitis – possible etiologies and complications and agrees
with pharmacologic and non-pharmacologic treatment plan (AII)
Recommendation 19. Aware of the dose, frequency, indications and side
effects of the medications given (AII)
Recommendation 20. Aware of the importance of compliance with
antibiotic treatment and follow-up (AII)
Lack of knowledge about the disease and understanding about
the role of the prescribed medications in the treatment of the disease
are associated with poor compliance with medication. Healthcare
providers should give patients enough education about their disease
and counseling regarding the treatment may be useful in improving
compliance.59
At the end of the consultation, the patient must have agreed
with the therapeutic and non-therapeutic interventions that will
be implemented. There should be shared decision making in the
management of the patient’s condition, wherein the different options,
together with their benefits and harms, are presented to the patients
to address their expectations and concerns with respect to their values,
preferences and circumstances. The patient must know the dose,
frequency, indications, and side effects of the medications prescribed. If
an antibiotic was given, the patient must understand the importance of
adherence with the treatment to avoid antimicrobial resistance.60
Recommendation 21. Advise patient to follow-up after 7 days to assess
for improvement or at any time if with worsening of symptoms (AII)
Patients are recommended to follow-up after 7 days to assess for
improvement or at any time if with signs and symptoms of suppurative
complications of GAS pharyngitis. With antibiotics, significantly
more people with acute sore throat were symptom free at days 3 and
7 compared with placebo. At day 3, 51% were symptom free with
antibiotics compared with 34% with placebo. At day 7, most people in
both groups were symptom free. This is based on low-quality evidence.1
Second Visit
History and Physical Exam
On the second visit, patients must be reassessed for improvement
in symptoms, adherence to medications and occurrence of adverse
effects and examined for presence of signs of suppurative complications
if with no improvement or if with worsening of symptoms
Recommendation 22. Re-evaluate the presence of throat pain and its
intensity, fever, pharyngeal congestion, and tonsillar exudates (AII)
Non-improvement in symptoms on the follow-up visit may warrant
a change in the antibiotic. Although, most improve with treatment,
210
a small percentage may have persistent symptoms. In a prospective
cohort study among 14610 adults with acute sore throat, 14.2%
reconsulted with new or unresolving symptoms. A modified Centor score
of 4 predicted new or unresolving symptoms only at high scores.25 In
another prospective study involving a cohort of 2000 children 6 months
to 18 years of age with sore throat, a higher percentage developed
recurrent tonsillopharyngitis (306; 15.3%) with 236 (12.3%) occurring
within a shorter time from onset illness - 10 to 14 days and thirty four
(1.7%) within 21–30 days after the index positive GABHS culture. The
incidence of complications in this study was also not affected by poor
medication compliance.61
Recommendation 23. Assess patient adherence to treatment (AII) and
explore reasons for non-adherence (AIII)
With adequate therapy, most of the patients, especially
adolescents and adults, are symptom-free within 48 h. If with no
improvement in symptoms, adherence to medications must be
assessed. 62 Adherence with prescribed medications may be an issue
for some people especially with antibiotics that require frequent
dosing or longer treatment duration. 1 In a systematic review, lack of
adherence was associated with penicillin treatment failure for GAS
pharyngitis. 63
Reasons for non-adherence to treatment must be explored for it
to be adequately addressed on the second visit. Possible causes of nonadherence include confusion with dosing and duration of treatment,
complex treatment plans, difficulty in buying the medications,
difficulty in ingesting the medications, insufficient communication
between patient and provider and duration of treatment.64-66 Quick
recovery and slow recovery were also found to lead to non-adherence
to antibiotic in pediatric patients with pneumonia and prescribed with
oral antibiotics.66 On the other hand, increasing age and satisfaction
with information given by the physician are associated with adherence
to treatment.64
Recommendation 24. Ask for presence of any adverse drug event (AIII)
The occurrence of any adverse drug event to the initial antibiotics
prescribed will warrant a change in antibiotics. Adverse drug reactions
lead to morbidity and mortality.67 It also poses as a barrier to patient’s
medication-taking behavior.68
Recommendation 25. Examine for signs of suppurative complications if
with no improvement in symptoms (AII)
Persistence of symptoms of streptococcal throat infection
may suggest the development of a suppurative complication.4 In
the prospective cohort study by Little, et al., major suppurative
complications of acute sore throat including peritonsillar abscess and
otitis media, were observed in 1.3% of patients within a month of the
index episode, regardless of whether they were given antibiotics, not
given antibiotics, or given delayed antibiotics. In multivariate analysis,
predictors of complications were severe tonsillar inflammation (OR
1.92, 95% CI 1.28 to 2.89) and severe earache (OR 3.02, 96% CI 1.91 to
THE FILIPINO FAMILY PHYSICIAN
4.76). Both the Centor and the FeverPAIN scoring system (score of 4 or
more) had low sensitivity for complications.69
Diagnostic Tests
Recommendation 26. Offer throat swab and culture if initial antibiotic
treatment fails (AII)
Follow-up posttreatment throat cultures or RADT are not
recommended routinely but may be considered if symptoms worsen
rapidly or significantly.4 End of antibiotic treatment throat swabbing
is not recommended except in the following situations: those with
a history of rheumatic fever, GAS recurrence, where it is the child’s
or adolescent’s third or more consecutive symptomatic GAS positive
pharyngitis in a three-month period, where there is recurrent GAS
pharyngitis within families, those who develop GAS pharyngitis
during outbreaks in a closed or partially-closed community, those who
develop GAS pharyngitis during outbreaks of acute rheumatic fever or
post streptococcal glomerulonephritis, and lastly, those who remain
symptomatic after completing their full course of antibiotics.70
GAS carrier state should not be treated with antibiotics and
therefore a follow-up culture of throat swabs should not be routinely
done in asymptomatic patients who have completed a course of therapy
for GAS.71 Streptococcus carriers are unlikely to spread the organism
to their close contacts and are at very low risk, if any, for developing
suppurative complications or non-suppurative complications.
Pharmacologic Interventions
Recommendation 27. If with symptom improvement within 1 week,
advise to complete the prescribed antibiotic regimen (AI)
Most oral antibiotics must be taken to complete 10 days to achieve
eradication of streptococcal infection of the throat.4,6,18
Recommendation 28. If with no improvement or if with worsening
of symptoms despite adherence or if with adverse reactions to the
previously prescribed antibiotics, offer change in antibiotics (AIII)
Clinical response is often observed within 24-48 hours in patients
prescribed with antibiotics for streptococcal pharyngitis. Usually selflimited, symptoms of pharyngitis resolve within a few days of illness
onset even without treatment. The persistence of symptoms suggest
either of 2 things - the development of suppurative complication or that
the patient is a chronic carrier of GAS with an ongoing viral pharyngitis.4
In case of first-line treatment failure in children, indications for retreatment include a history of rheumatic fever, invasive streptococcal
disease (e.g. suppurative complications) and when tonsillectomy
is being considered. Second-line antibiotics are recommended as
treatment.6
Cephalosporins may be more effective in the treatment of
streptococcal pharyngitis than penicillin. In a meta-analysis overall
OR for clinical cure was 2.33 (95% CI: 1.84 –2.97) with prescribing
cephalosporins such as cephalexin, cefadroxil, cefuroxime, cefpodoxime,
VOL. 59 NO. 2 DECEMBER, 2021 cefprozil, cefixime, ceftibuten and cefdinir.72 Though associated with
a higher cost of treatment, cephalosporins may be also be offered
as empiric treatment for streptococcal pharyngitis, if a change in
antibiotic is being considered.
In cases of adverse events, the initially prescribed antibiotics
should be changed to decrease complications and to improve adherence
to antibiotic treatment.67,68 Alternative options for antibiotic therapy
include cephalosporins, macrolides and clindamycin.1,4,5,62
Recommendation 29. If with no improvement or worsening of symptoms
because of poor adherence, continue the first antibiotic prescribed and
complete the prescribed regimen. (AIII)
After exploring for reasons behind non-adherence, the patient
must be advised to continue the initially prescribed antibiotics and
complete the recommended duration of treatment provided.
Non-pharmacologic Interventions
Patient Intervention
Recommendation 30. If symptoms are still present, reinforce advice on
use of supportive treatment and home remedies for symptomatic relief
(AIII)
Like in the first consult, patients may be advised to increase oral
fluid intake to ensure adequate hydration. Household remedies such as
salt-water gargles, medicated lozenges and throat sprays may also be
continued.
Recommendation 31. Reinforce health education regarding possible
complications and treatment of Streptococcal pharyngitis (AIII)
To ensure understanding, information regarding possible
complications and treatment of streptococcal pharyngitis must be
provided.
Recommendation 32. Reinforce education on hand hygiene and cough
and sneeze etiquette to reduce transmission (AIII)
To reduce transmission at home and in the workplace, advise on
hand hygiene and cough and sneeze etiquette must be reiterated.
Recommendation 33. Reinforce education on the proper dosage and
timing of intake of antibiotics and provide counseling on adherence to
medication (AII)
Information regarding the proper dosage, timing and duration of
intake of antibiotics must be provided again to the patient. Adherence to
medication may be improved by ensuring that the patient understands
the information provided through improved communication between
patient and the physician. Simplification of dosing, reminders regarding
medications such as texts via short messaging system, and counseling
are other interventions that can be implemented to improve adherence.65
211
Counseling approaches such as motivational interviewing73 and
the CEA method74 have been found in studies to be more effective than
the usual patient advice in medication adherence among patients with
chronic diseases and those on treatment for pulmonary tuberculosis,
respectively. Patient-centered communication, which is central to the
2 counseling methods, is utilized to explore barriers to medication
adherence, elicit patient’s concerns and fear regarding potential
adverse effects of treatment and to facilitate involvement of patient in
the implementation of the treatment plan.
Family Intervention
Recommendation 34. Reinforce health education of family regarding
transmission, treatment and possible complications of Streptococcal
pharyngitis for pediatric patients. (AIII)
Recommendation 38. Aware of the diagnostic tests if any will be
conducted, its benefit and harm
Patients for whom tonsillectomy is indicated must be aware of the
reasons for recommending the procedure – its potential benefits, and
also the risks that come with it.
Declaration of potential conflict of interest
The PAFP received a financial grant from Reckitt Benckiser
(Philippines), Inc. to aid in the development of clinical pathways.
However, the company had no direct involvement in any of the steps
of pathway development, nor did it have any influence on the final
recommendations that were formulated.
Consensus Panel
Education of families regarding transmission, possible
complications and treatment of streptococcal pharyngitis must
be reinforced. Written or verbal instructions regarding dosing and
administration of new antibiotics must be provided to the parents
of children with streptococcal infection. Possibility of referral for
tonsillectomy must be discussed if there is failure of treatment
or recurrent tonsillopharyngitis despite adequate adherence to
treatment.
1.
2.
3.
4.
5.
6.
7.
Community Intervention
Recommendation 35. Explore and educate on possible occupational
practices and exposure that could be triggers (AIII)
Importance of avoiding irritants in the community and in the
workplace must be reiterated.
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2.
3.
Patient Outcomes
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