While pharyngitis is a common primary care complaint, evidence reveals that this diagnosis is an area where antibiotic therapy is frequently misused. Appropriate diagnosis and management of pharyngitis is crucial to ensure antimicrobial stewardship and improve patient safety and outcomes. Pharyngitis etiologies include both infectious and noninfectious sources such as bacteria, viruses, fungal organisms, trauma, irritants, laryngopharyngeal reflux, and medications. Clinicians need to obtain a thorough history and careful physical examination, along with appropriate diagnostic testing when indicated, to ensure treatment plans are targeted toward the most likely pharyngitis etiology.
Key points
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Etiologies of pharyngitis include viral, bacterial, fungal organisms, trauma, medication side effects, allergens, and irritants.
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Serious and life-threatening complications can develop when bacterial (especially group A streptococcus) pharyngitis infections are not appropriately and promptly treated; however, misdiagnosis of other infectious and noninfectious causes of pharyngitis also results in potentially serious complications.
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Thorough history-taking and skilled physical examination along with the utilization of clinical decision tools such as Centor criteria, McIsaac, and Fever-PAIN coupled with appropriate testing can help clinicians ascertain the appropriate treatment and avoid prescribing unnecessary antibiotics that can lead to adverse events and antibiotic resistance.
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Recurrent or persistent cases of pharyngitis are most commonly caused by treatment regimen nonadherence or misdiagnosis.
Introduction
Pharyngitis is a common diagnosis in the primary care office making up an estimated 24 million cases per year in the United States. Pharyngitis is defined as inflammation of the pharynx and adjacent tissues, and the most common etiologies include viral, bacterial, or fungal origin. Less common causes of pharyngitis include trauma, medication side effects, allergies, and irritants. Even though the single most common cause of pharyngitis is viral with approximately 50% to 80% of cases, and group A streptococcal pharyngitis makes up only about 10% of cases, more than 60% of patients are treated with antibiotics. Utilizing clinical decision tools, ensuring appropriate testing, and following current guidelines can help clinicians ascertain the appropriate treatment and avoid prescribing unnecessary antibiotics that can lead to adverse events and antibiotic resistance.
Etiology
The main 2 categories of pharyngitis etiology are infectious and noninfectious causes. Infectious causes of pharyngitis include viral, bacterial, and fungal causes. Noninfectious causes include trauma such as intubation, accidents, voice strain, irritants such as chemicals, pollutants, smoking or inhalation injury, environmental allergens, stomach acid (as seen in laryngopharyngeal reflux [LPR]), dry or cold air, and medication side effect.
Infectious Causes
Viral pathogens
The majority of infectious pharyngitis cases is due to viral pathogens. The leading viral causes of pharyngitis include rhinovirus, adenovirus, and coronavirus (including coronavirus disease 2019 [COVID-19]). Influenza, parainfluenza, and respiratory syncytial virus are other common viral causes. Less common viral causes include human immunodeficiency virus (HIV), herpes, Epstein-Barr, cytomegalovirus, and coxsackie viruses. , ,
Bacterial pathogens
Group A streptococcus (GAS) is thought to be the most common bacterial pathogen responsible for pharyngitis making up approximately 5% to 15% of cases in adults and 20% to 30% of cases in children. Group C and G streptococcus, Arcanobacterium haemolyticum , Fusobacterium necrophorum , Mycoplasma pneumoniae , Chlamydia pneumoniae , and Corynebacterium diphtheriae are other bacterial causes. , Some of these less common bacterial causes are more likely to be found in certain patient populations. For example, Group C and G streptococcus and F necrophorum are more likely to be found in outbreaks on college campuses and in student health clinics. Other pathogens such as C diphtheriae are more likely to be found in underdeveloped countries where lack of access to care and low vaccination rates contribute to higher prevalence. High-risk sexual behavior may place patients at risk for rare causes of bacterial pharyngitis from sexually transmitted infections such as Treponema pallidum and Neisseria gonorrhoeae as well as from viruses such as HIV. , ,
Fungal pathogens
Candida albicans is the main fungal pathogen that can cause pharyngitis, but it is mainly seen in the immunocompromised patient population or those using inhaled corticosteroids.
Noninfectious Causes
Noninfectious causes are a diagnosis of exclusion and are not well-studied. A detailed history will aid clinicians in appropriately identifying these causes of pharyngitis.
Trauma
Use of laryngeal mask airways or tracheal intubation increases the risk of trauma-induced pharyngitis. In patients undergoing intubation, a range of 28% to 70% report sore throat, and about 3% to 21% report sore throat after laryngeal mask airway use. Snoring, yelling, and frequent talking can also lead to sore throat.
Irritants
Smokers and patients exposed to second-hand smoke may also develop symptoms of pharyngitis. Increased use of electronic cigarettes and inhaled marijuana, especially among adolescents and young adults, has resulted in increased incidence of irritant-induced pharyngitis. , Air pollution most commonly seen in large cities and due to frequent exposure to traffic fumes can cause sore throat. Industrial particulates such as seen with woodworking, cement working, or exhaust fumes from industrial machines as well as chemicals such as boron acid, volatile organic compounds, and oil spills also contribute to work-related injuries. Indoor air pollution, often termed “sick building syndrome,” can cause irritant-induced pharyngitis along with a myriad of other complaints that are generally caused by faulty air cooling/heating/ventilation systems or mold. Cold temperature and low humidity are also factors that can lead to pharyngitis.
Laryngopharyngeal reflux
LPR is a common cause of pharyngeal irritation. It is difficult to diagnose due to unreliable findings on laryngoscopy and pH monitoring but often responds well to a trial of proton pump inhibitors (PPIs).
Medications
The most common medications that may cause throat pain usually occur as a result of pill esophagitis, which can cause inflammation of the esophagus and surrounding tissues including the pharynx. Antibiotics (most notably doxycycline), nonsteroidal anti-inflammatory drugs (NSAIDs), and bisphosphonates are the most common medications involved, but often the likelihood of this adverse effect occurring can be mitigated by having patients take these medications while seated upright, with a large glass of water, and not to recline or lie down directly after taking the medications. Angiotensin-converting enzyme-inhibitors and chemotherapy are other medications that may also contribute to symptoms of sore throat.
Clinical presentation
The primary presenting symptom of pharyngitis, regardless of etiology, is sore throat. Other presenting symptoms and signs of pharyngitis may vary by pathogen and cause. Group A streptococcal pharyngitis generally presents with tonsillar exudate, fever, and/or tender anterior chain lymphadenopathy. It is extremely rare in children aged under 3 years. Viral pharyngitis is more likely to be accompanied by cough and nasal congestion. Epstein-Barr virus (EBV) and cytomegalovirus (CMV) are 2 viral pathogens that can cause infectious mononucleosis, which is recognized by a triad of symptoms including fever, pharyngitis, and lymphadenopathy. , Candidiasis is more likely to present with white or erythematous patches in the mouth and throat and is more common in the immunocompromised host although can also be present in immunocompetent hosts. LPR usually presents with pharyngeal erythema and may be accompanied by hoarseness, sore throat, throat clearing, globus sensation, and cough.
Evaluation
Clinical Decision Tools
Clinical decision tools that have been substantiated specifically for streptococcal pharyngitis include Centor, McIsaac (which is also known as Modified Centor), and Fever-PAIN, which are all equivocal. When coupled with appropriate rapid testing, they can help decrease inappropriate antibiotic use. ,
Centor criteria give 1 point for each of the following: lack of cough, tonsillar exudate or swelling, fever (temperature ≥100.4°F), swollen, tender anterior cervical chain lymphadenopathy.
McIsaac (modified Centor) gives 1 point to each of those listed in Centor, but also adds age as a factor by affording an additional 1 point to those patients aged 3 to 14 years, 0 points for those aged 15 to 44 years, and −1 (subtract 1 point) for those aged 45 years and older.
Fever-PAIN gives 1 point for each of the following: absence of cough or coryza, feverishness in the last 24 hours, intensely inflamed tonsils, purulent tonsils, presentation within 3 days of symptom onset.
Each of these clinical decision tools uses the same risk scoring with a score of 0 to 1 being considered low risk, 2 to 3 intermediate risk, and 4 to 5 high risk. Patients who are at low risk should not have rapid antigen testing (RADT). Those at intermediate risk should have RADT. Patients determined to be high risk based on one of these tools can either have rapid testing done or can be empirically treated with antibiotics , ( Table 1 ).
| Criteria | Centor | McIsaac/Modified Centor | Fever-PAIN |
|---|---|---|---|
| Lack of cough | +1 | +1 | +1 |
| Tonsillar exudate or swelling | +1 | +1 | Not applicable |
| Fever (≥100.4°F) | +1 | +1 | +1 |
| Swollen, tender anterior cervical chain lymphadenopathy | +1 | +1 | Not applicable |
| Age | Not applicable | 3–14 y = +1 15–44 y = 0 ≥45 y = −1 | Not applicable |
| Purulent tonsils | Not applicable | Not applicable | +1 |
| Intensely inflamed tonsils | Not applicable | Not applicable | +1 |
| Presentation within 3 d of symptom onset | Not applicable | Not applicable | +1 |
| Risk score | 1–1, low risk; 2–3, intermediate risk; 4–5, high risk | ||
Testing
RADT has been validated for use with the clinical decision tools aforementioned. Another type of rapid testing that utilizes nucleic acid amplification techniques is available in the United States and is more sensitive and specific. However, it is also more expensive and more research needs to be done in conjunction with appropriate clinical decision tools in order to validate its use.
Throat culture is not indicated in the majority of adult patients but can be considered in patients who are high risk of complications such as immunocompromised patients. Both the Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics state that children and adolescents should undergo throat culture done if RADT is negative and then be appropriately treated with antibiotics if throat culture returns positive for streptococcus due to this age group having high risk of complications including peritonsillar abscess, rheumatic fever, and poststreptococcal glomerulonephritis. However, this has not recently been found to be cost-effective in the United States due to the fact that the prevalence of rheumatic heart disease is extremely low. , If RADT is negative for GAS but the patient has severe symptoms, consider Group C or Group G streptococcus, which would require a throat culture for diagnosis of this strain.
For comparison, RADT has a sensitivity of diagnosing GAS infection of 59% to 96% depending on which type is used, nucleic acid amplification testing has a sensitivity of 93% to 99%, and throat culture has a sensitivity of 90% to 95%. ,
Viral testing may be of help in diagnosing pharyngitis due to COVID-19, influenza, mononucleosis, or HIV. Most primary care offices have access to point of care COVID-19 and influenza testing, which may be helpful in diagnosis and determining the etiology of viral pharyngitis. EBV and CMV testing may be performed to aid in the diagnosis of mononucleosis. EBV testing can include viral capsid antigen (VCA), early antigen, EBV nuclear antigen (EBNA), and monospot testing. Primary current EBV infection can be suspected when patients have anti-VCA immunoglobulin M (IgM) but do not have antibodies to EBNA or if patients have high or increasing levels of anti-VCA IgG and no antibodies to EBNA. Past infection is evidenced by antibodies to both VCA and EBNA. In general, monospot testing is not recommended by the CDC as there are often false negatives and false positives, and it is not a very accurate test in children as the antibodies that monospot tests for are often not present in children infected by EBV. A CBC may also be helpful in mononucleosis as it will often show lymphocytosis with atypical lymphocytes at levels of 10% or more. Mononucleosis caused by CMV is best diagnosed by a positive IgM serology.
Pharyngitis as a result of candida infection is usually a clinical diagnosis. If it persists despite treatment, cultures and sensitivities may be helpful. If the lesion can be visualized, a microbial culture can be taken of the lesion. If there is no visible lesion but candida is considered to be a likely diagnosis, a whole saliva sample can be taken. If dentures are involved, a sample should also be taken from both the dentures and the palate.
Laryngoscopy and pH monitoring are the tests currently available to test for LPR. However, they are notably inaccurate and often miss the diagnosis. A trial of PPIs is considered both diagnostic and therapeutic in many cases.
Treatment
Infectious Causes
Viral pathogens
The mainstay of treatment in viral pharyngitis cases is supportive therapy. In certain specific viral illnesses such as influenza A and B, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and herpes simplex viruses, specific antiviral therapies can be used, which may help reduce the severity and length of illness. For influenza A and B, oseltamivir, zanamivir, peramivir, or baloxavir can be prescribed. Tamiflu is the only anti-influenza agent approved for use in infants and children aged 14 days to 7 years, while zanamivir is indicated in adults and children aged 7 years and older, peramivir is indicated in adults and children aged 13 years and older, and baloxavir is indicated in adults and children aged 12 years and older. Pharyngitis can be a presenting symptom in oral mucocutaneous herpes simplex infections, and appropriate antiviral therapy with acyclovir, valacyclovir, famciclovir, or ganciclovir will improve the associated sore throat. Antiviral therapy has not been shown to be effective in EBV-induced and CMV-induced infectious mononucleosis, and first-line recommended treatment is supportive therapy only with close monitoring for complications. Acute onset upper respiratory symptoms including fever, nonexudative pharyngitis, and diffuse adenopathy in patients with history of high-risk sexual behavior is concerning for acute HIV infection and requires appropriate testing and treatment if this diagnosis is confirmed.
Supportive
Supportive therapies to consider include NSAIDs, acetaminophen, corticosteroids, topical anesthetics, medicated throat lozenges, and salt water gargles. , NSAIDs have proven to be more effective in reducing tonsillar swelling while also managing pain and fever compared to acetaminophen. While corticosteroids are effective in reducing pain and swelling, these medications carry increased risk of side effects compared to NSAIDs, which resulted in guidelines advising against corticosteroid use in pharyngitis. However, more recent studies demonstrate that a single dose of a high-potency corticosteroid such as dexamethasone, administered within 24 hours of onset of symptoms, is more effective in rapidly reducing pain and swelling compared to NSAIDs alone in patients aged 5 years and older with GAS pharyngitis. The suggested dose for dexamethasone in GAS cases is 0.6 mg/kg (maximum dose 10 mg) by mouth. Intravenous or intramuscular corticosteroid therapy is recommended in all cases of airway compromise in the setting of pharyngitis. Topical anesthetics and medicated throat lozenges are effective in reducing pain but require frequent redosing approximately every 2 hours.
Bacterial pathogens
Oral penicillin V potassium remains the first-line therapeutic agent recommended for the treatment of GAS pharyngitis. Given the low cost, minimal side effect profile, and the ongoing sensitivity of GAS to this agent, penicillin is considered a safe and effective treatment option. , Amoxicillin is an equally effective alternative with the benefit of available liquid formulations for patients who cannot tolerate tablets. A single intramuscular dose of penicillin G benzathine is another alternative therapy. For patients with type IV hypersensitivity reactions (ie, rash) to penicillin, cephalosporins (eg, cephalexin) are effective and safe. In the case of more severe penicillin allergic reactions such as anaphylaxis (type 1 hypersensitivity), macrolides such as azithromycin and clarithromycin, or oral clindamycin are recommended therapies. With the exception of azithromycin, which requires a 5 day course of therapy, all oral antibiotics noted here require a 10 day course of treatment. Antibiotic treatment of group C and G streptococcal pharyngitis is not recommended as these non-GAS infections do not progress to rheumatic fever; however, antibiotic therapy may reduce pain. Appropriate antibiotic therapy should be initiated in the setting of positive RADT and/or throat culture results. Patients with streptococcal bacterial pharyngitis should not be cleared to return to school or work until fever has resolved and/or a minimum of 24 hours of antibiotic therapy has been completed. Patients with GAS pharyngitis require re-evaluation if symptoms worsen despite 5 days of appropriate treatment. Hospitalization is indicated in cases of sepsis, airway compromise, need for intravenous antibiotic therapy, and/or suspicion for Lemierre syndrome.
Gonococcal pharyngitis treatment regimens are the same as gonococcal genitourinary infections. Patients should receive intramuscular ceftriaxone along with oral doxycycline or azithromycin to reduce the risk of resistance and because there is 20% to 54% rate of coinfection with chlamydia. Sexual contact should be avoided until therapy is completed and symptoms have resolved, and patients should be counseled regarding the need for condom use with all sexual contact.
Fungal pathogens
Fungal pharyngitis, most commonly caused by C albicans , should be treated with either oral nystatin solution for 7 to 10 days or fluconazole 100 to 200 mg tablet daily for 7 to 14 days. If inhaled corticosteroid use is the suspected precipitating factor, education regarding rinsing mouth after inhaler use should be provided.
Surgical management
Definitive surgical intervention with tonsillectomy should be considered in patients with a high frequency of recurrent GAS or other bacterial pharyngitis, those with multiple antibiotic allergies complicating management, or those with a history of serious complications such as peritonsillar abscess. , When considering surgical intervention, clinicians should be cognizant that the risk and incidence of bacterial pharyngitis decreases with age, especially in patients aged older than 10 years. High frequency of recurrence is generally defined as 7 episodes in a 1 year period, 5 episodes per year over a 2 year period, or 3 episodes per year over a 3 year period. While tonsillectomy does reduce the risk of tonsillitis, studies have only demonstrated moderate long-term benefit in reducing recurrent sore throat/pharyngitis episodes.
Noninfectious Causes
Trauma
Definitive treatment of trauma-induced pharyngitis includes removal or resolution of the inciting trauma while providing supportive care until symptoms resolve. In the case of postoperative pharyngitis, the risk of occurrence can be reduced with the use of inhaled fluticasone propionate, intravenous dexamethasone, and lidocaine. Additionally, the use of topical NSAIDs, lozenges, and ketamine gargles postoperatively reduce pain and swelling. Addressing the underlying cause of the turbulent airflow in snoring-induced pharyngitis is the preferred treatment, but supportive therapies provide symptomatic relief while diagnostic workup and treatment plans are developed. Sore throats due to excessive talking or yelling should be managed with voice rest and supportive therapies.
Irritants
Avoidance of irritants or allergens causing pharyngitis is the primary treatment in these cases. For instance, smoking cessation counseling should be provided to those using cigarettes, pipes, cigars, hookah, electronic cigarettes, and inhaled marijuana. , ,
For allergen-induced pharyngitis, reducing the risk of exposure to inciting allergens is recommended when possible. However, for common seasonal and environmental allergens such as pollen, grass, ragweed, and dust mites, this is not realistic. While maintaining a clean home environment is recommended to reduce dust mite exposure, evidence has not demonstrated a reduction in allergy symptoms and the need for medication with the use of dust mite-proof mattresses, pillows, quilt covers or similar products, and high-efficiency particulate air filters. Age-appropriate treatment of allergic rhinitis with associated pharyngitis is recommended. Treatment options include intranasal corticosteroids, oral antihistamines, intranasal antihistamines, combined intranasal corticosteroid and antihistamine formulations, oral decongestants, intranasal cromolyn, intranasal ipratropium, and leukotriene receptor antagonists. Of note, when selecting allergy treatments, clinicians must consider that intranasal corticosteroids, antihistamines, and combined corticosteroid-antihistamine formulations can potentially cause pharyngitis.
Laryngopharyngeal reflux
LPR-induced pharyngitis treatment is focused on addressing the underlying gastroesophageal reflux and should include the elimination of inciting foods, weight loss, smoking cessation, limiting/eliminating alcohol, and avoiding food intake prior to bedtime. Additional treatment options include pharmacologic therapy with PPIs or combined PPIs and histamine 2-receptor antagonists for cases resistant to PPIs alone. Surgical intervention with Nissen fundoplication may be indicated in patients who do not respond to pharmacologic therapy; however, outcome studies have resulted in conflicting evidence as to whether this treatment is effective in resolving LPR resistant to PPI therapy. The proposed reasoning for these variable outcomes is misdiagnosis of LPR as the cause of pharyngitis resulting in a lack of response to PPI therapy and no improvement following surgery.
Medications
Medication-induced pharyngitis treatment includes discontinuation or substitution of inciting medications if clinically appropriate, and/or supportive therapies. In cases of pill esophagitis with associated pharyngitis, patients should be educated regarding the need to take potentially problematic medications with a full glass of water while sitting upright and remaining upright for 30 minutes after medication administration.
Emerging therapies
During and following the 2020 COVID-19 pandemic, pharyngitis cases due to infection with SARS-CoV-2 dramatically increased. This viral pharyngitis can be appropriately treated with antiviral therapies approved in the treatment of COVID-19 and include oral nirmatrelvir/ritonavir and intravenous remdesivir. Patients who do not meet criteria for these pharmacologic therapies should be treated with supportive therapies previously discussed.
Another emerging clinical trend now widely accepted following the COVID-19 pandemic is the use of telemedicine in evaluating and treating patients with pharyngitis. While patients can provide equivalent history in both face-to-face and telemedicine visits, caution should be exercised when prescribing antibiotics for GAS pharyngitis following telemedicine encounters due to the limitations of effective patient self-examination. Studies show that patients overreport tonsillar exudate, erythema, and tender anterior cervical lymphadenitis, and patients have difficulty providing clinically useful oropharyngeal images. This imprecision in self-examination may result in falsely elevated clinical decision tool scores that can lead to inappropriate empiric antibiotic therapy. The risks versus benefits of antibiotic use should be carefully considered and discussed with patients when assessing pharyngitis via telemedicine encounters.
Complications
The majority of serious pharyngitis complications is observed in GAS pharyngitis and includes the development of antibiotic resistance, adverse reactions to antibiotics, epiglottitis, peritonsillar abscess, retropharyngeal abscess, rheumatic fever and heart disease, poststreptococcal glomerulonephritis, and Lemierre syndrome. , Lemierre syndrome is an extension of bacterial pharyngitis into the lateral pharyngeal space with the development of jugular vein thrombophlebitis resulting in bacteremia and sepsis. Lemierre syndrome is a known complication of GAS infection, but the primary cause is F necrophorum pharyngitis. Serious complications resulting from GAS pharyngitis are more common in children and adolescents; therefore, the threshold to initiate antibiotic therapy in this population should be lower as conditions such as peritonsillar abscess, rheumatic fever, and poststreptococcal glomerulonephritis can be avoided with initiation of appropriate antibiotic therapy within 9 days of onset of symptoms. In the United States, rheumatic fever has an estimated incidence of 0.5 episodes per 100,000 people with rheumatic heart disease occurring in 50% to 70% of rheumatic fever cases.
In all cases of pharyngitis, complications include loss of productivity (absence from work), education setbacks (absence from school), social isolation, and adverse reactions to therapies. Prompt and accurate diagnosis of pharyngitis etiology followed by appropriate management reduces the risk of these complications. Of particular concern is the overuse of antibiotics in pharyngitis cases. Antibiotic use, both appropriate and inappropriate, increases the risk of resistance development, adverse reactions including allergic reactions, Clostridium difficile colitis (especially with clindamycin use), and increased financial burden on patients and the health care system.
Recurrence management
When bacterial pharyngitis cases do not respond to appropriate antibiotic therapy or there is recurrence, high suspicion for misdiagnosis should exist and consideration be given to possible viral or noninfectious etiologies. If antibiotic therapy was initiated on the basis of RADT results alone, a throat culture should be obtained to confirm diagnosis as well as antibiotic sensitivity.
Confirmed recurrence or persistence of bacterial pharyngitis, particularly GAS pharyngitis, is most often due to noncompliance with or nonadherence to the treatment course, but antibiotic resistance should be considered. For GAS pharyngitis, in patients initially treated with a 10 day course of penicillin, recurrent cases can be effectively managed with amoxicillin/clavulanate, clindamycin, or intramuscular penicillin G benzathine. Patients with penicillin allergies who were initially managed with a first-generation cephalosporin can be treated with a third-generation cephalosporin. , When recurrence of viral pharyngitis occurs, consideration should be given to superimposed bacterial etiology or some other noninfectious cause. Infectious pharyngitis, particularly bacterial cases, are contagious; therefore, toothbrushes should be changed and dentures, retainers, and other oral devices thoroughly cleansed and disinfected within 24 to 48 hours after initiation of treatment to prevent reinfection.
Emerging evidence reveals that approximately 10% of bacterial pharyngitis cases in adolescents and young adults are due to F necrophorum , an obligate anaerobic gram-negative bacillus. Patients presenting with worsening symptoms, such as rigors, night sweats, and unilateral pain despite appropriate antibiotic therapy for GAS, should be evaluated for Lemierre syndrome. This diagnosis requires prompt hospitalization for imaging, intravenous antibiotic therapy, and polymerase chain reaction testing for F necrophorum as this organism is the most common cause of Lemierre syndrome. ,
Summary
While pharyngitis is a common primary care complaint, evidence reveals that this diagnosis is an area where antibiotic therapy is frequently misused. Appropriate diagnosis and management of pharyngitis is crucial to ensure antimicrobial stewardship and improve patient safety and outcomes. Pharyngitis etiologies include both infectious and noninfectious sources such as bacteria, viruses, fungal organisms, trauma, irritants, LPR, and medications. Clinicians need to obtain a thorough history and careful physical examination, along with appropriate diagnostic testing when indicated, to ensure treatment plans are targeted toward the most likely pharyngitis etiology.
Clinics care points
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History combined with physical and risk score calculators should be used to increase the accuracy of testing and diagnosis of pharyngitis.
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The majority of pharyngitis is nonbacterial in etiology, and providers should practice cautious antibiotic stewardship when managing these cases.
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Practitioners should emphasize conservative management in adults and more proactive empiric treatment in pediatric patients.
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