Evaluation of acute pharyngitis in adults
- Anthony W Chow, MD, FRCPC, FACP
Anthony W Chow, MD, FRCPC, FACP
- Professor Emeritus of Medicine
- University of British Columbia
- Shira Doron, MD
Shira Doron, MD
- Associate Professor of Medicine
- Tufts University School of Medicine
Acute pharyngitis is one of the most common conditions encountered in office practice, accounting for 12 million ambulatory visits in the United States annually . While group A streptococcus is an important treatable infection, it accounts for a minority (approximately 5 to 15 percent) of adults presenting with pharyngitis . Despite this, a majority of patients with pharyngitis receive presumptive antibiotic therapy. One report estimates that 60 percent (95% CI 57-63 percent) of adults seen in a United States clinic in 2010 for a complaint of sore throat received an antibiotic prescription, with a trend toward prescribing broader spectrum antibiotics (azithromycin) rather than narrow spectrum antibiotics (eg, penicillin) . Overtreatment of acute pharyngitis is a major cause of inappropriate antibiotic use, which can be avoided by a systematic approach to evaluation and treatment .
The etiology, general approach to, and evaluation of acute pharyngitis in adults will be reviewed here. The treatment and complications of group A streptococcal pharyngitis and symptomatic management of pharyngitis are discussed separately. (See "Treatment and prevention of streptococcal tonsillopharyngitis" and "Symptomatic treatment of acute pharyngitis in adults".)
Infectious causes — Multiple pathogens can cause pharyngitis (table 1) . Although viruses are believed to cause most cases of pharyngitis, the relative frequency of particular pathogens in adults is uncertain, since most studies are old and include both children and adults [6-8]. Identification of a particular microorganism, by culture or rapid antigen detection, does not prove causation of the pharyngitis since many organisms colonize the upper respiratory tract without causing disease.
Group A streptococcus (GAS) — The most important treatable agent is group A streptococcus (GAS). Approximately 5 to 15 percent of sore throats in adults yield positive cultures for GAS .
Clinical features of GAS include the sudden onset of sore throat, tonsillar exudate, tender cervical adenitis, and fever. Cough and significant rhinorrhea are usually absent. The Centor criteria (exudate, cervical adenopathy, fever history, and lack of cough) provide a clinical prediction rule with reasonable negative predictive value in excluding streptococcal pharyngitis [9,10]. (See 'Centor criteria' below.)
- Schappert SM, Rechtsteiner EA. Ambulatory medical care utilization estimates for 2006. Natl Health Stat Report 2008; :1.
- Snow V, Mottur-Pilson C, Cooper RJ, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med 2001; 134:506.
- Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997-2010. JAMA Intern Med 2014; 174:138.
- Linder JA, Stafford RS. Antibiotic treatment of adults with sore throat by community primary care physicians: a national survey, 1989-1999. JAMA 2001; 286:1181.
- Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am 2007; 21:449.
- EVANS AS, DICK EC. ACUTE PHARYNGITIS AND TONSILLITIS IN UNIVERSITY OF WISCONSIN STUDENTS. JAMA 1964; 190:699.
- Glezen WP, Clyde WA Jr, Senior RJ, et al. Group A streptococci, mycoplasmas, and viruses associated with acute pharyngitis. JAMA 1967; 202:455.
- Monto AS, Ullman BM. Acute respiratory illness in an American community. The Tecumseh study. JAMA 1974; 227:164.
- Cooper RJ, Hoffman JR, Bartlett JG, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med 2001; 134:509.
- Centor RM, Witherspoon JM, Dalton HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1981; 1:239.
- Huovinen P, Lahtonen R, Ziegler T, et al. Pharyngitis in adults: the presence and coexistence of viruses and bacterial organisms. Ann Intern Med 1989; 110:612.
- Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med 2010; 362:1993.
- Lapins J, Gaines H, Lindbäck S, et al. Skin and mucosal characteristics of symptomatic primary HIV-1 infection. AIDS Patient Care STDS 1997; 11:67.
- Valle SL. Febrile pharyngitis as the primary sign of HIV infection in a cluster of cases linked by sexual contact. Scand J Infect Dis 1987; 19:13.
- de Jong MD, Hulsebosch HJ, Lange JM. Clinical, virological and immunological features of primary HIV-1 infection. Genitourin Med 1991; 67:367.
- McMillan JA, Weiner LB, Higgins AM, Lamparella VJ. Pharyngitis associated with herpes simplex virus in college students. Pediatr Infect Dis J 1993; 12:280.
- Tustin AW, Kaiser AB. Life-threatening pharyngitis caused by herpes simplex virus, type 2. Sex Transm Dis 1979; 6:23.
- Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation 2009; 119:1541.
- Turner JC, Hayden FG, Lobo MC, et al. Epidemiologic evidence for Lancefield group C beta-hemolytic streptococci as a cause of exudative pharyngitis in college students. J Clin Microbiol 1997; 35:1.
- Centor RM, Atkinson TP, Ratliff AE, et al. The clinical presentation of Fusobacterium-positive and streptococcal-positive pharyngitis in a university health clinic: a cross-sectional study. Ann Intern Med 2015; 162:241.
- Gerber MA, Randolph MF, Martin NJ, et al. Community-wide outbreak of group G streptococcal pharyngitis. Pediatrics 1991; 87:598.
- Miller RA, Brancato F, Holmes KK. Corynebacterium hemolyticum as a cause of pharyngitis and scarlatiniform rash in young adults. Ann Intern Med 1986; 105:867.
- Morris SR, Klausner JD, Buchbinder SP, et al. Prevalence and incidence of pharyngeal gonorrhea in a longitudinal sample of men who have sex with men: the EXPLORE study. Clin Infect Dis 2006; 43:1284.
- Reintjes R, Dedushaj I, Gjini A, et al. Tularemia outbreak investigation in Kosovo: case control and environmental studies. Emerg Infect Dis 2002; 8:69.
- Meric M, Willke A, Finke EJ, et al. Evaluation of clinical, laboratory, and therapeutic features of 145 tularemia cases: the role of quinolones in oropharyngeal tularemia. APMIS 2008; 116:66.
- Amess JA, O'Neill W, Giollariabhaigh CN, Dytrych JK. A six-month audit of the isolation of Fusobacterium necrophorum from patients with sore throat in a district general hospital. Br J Biomed Sci 2007; 64:63.
- Batty A, Wren MW. Prevalence of Fusobacterium necrophorum and other upper respiratory tract pathogens isolated from throat swabs. Br J Biomed Sci 2005; 62:66.
- Jensen A, Hagelskjaer Kristensen L, Prag J. Detection of Fusobacterium necrophorum subsp. funduliforme in tonsillitis in young adults by real-time PCR. Clin Microbiol Infect 2007; 13:695.
- Batty A, Wren MW, Gal M. Fusobacterium necrophorum as the cause of recurrent sore throat: comparison of isolates from persistent sore throat syndrome and Lemierre's disease. J Infect 2005; 51:299.
- Linder JA. Sore throat: avoid overcomplicating the uncomplicated. Ann Intern Med 2015; 162:311.
- Mansel JK, Rosenow EC 3rd, Smith TF, Martin JW Jr. Mycoplasma pneumoniae pneumonia. Chest 1989; 95:639.
- Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev 2006; :CD000023.
- Glynn F, Fenton JE. Diagnosis and management of supraglottitis (epiglottitis). Curr Infect Dis Rep 2008; 10:200.
- Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg 1995; 112:375.
- Szuhay G, Tewfik TL. Peritonsillar abscess or cellulitis? A clinical comparative paediatric study. J Otolaryngol 1998; 27:206.
- Galioto NJ. Peritonsillar abscess. Am Fam Physician 2008; 77:199.
- Reynolds SC, Chow AW. Life-threatening infections of the peripharyngeal and deep fascial spaces of the head and neck. Infect Dis Clin North Am 2007; 21:557.
- ESCMID Sore Throat Guideline Group, Pelucchi C, Grigoryan L, et al. Guideline for the management of acute sore throat. Clin Microbiol Infect 2012; 18 Suppl 1:1.
- Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 2012; 55:1279.
- Tan T, Little P, Stokes T, Guideline Development Group. Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance. BMJ 2008; 337:a437.
- McIsaac WJ, Kellner JD, Aufricht P, et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA 2004; 291:1587.
- Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med 2012; 172:847.
- McIsaac WJ, Goel V, To T, Low DE. The validity of a sore throat score in family practice. CMAJ 2000; 163:811.
- Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev 2004; 17:571.
- Dagnelie CF, Bartelink ML, van der Graaf Y, et al. Towards a better diagnosis of throat infections (with group A beta-haemolytic streptococcus) in general practice. Br J Gen Pract 1998; 48:959.
- Roddey OF Jr, Clegg HW, Martin ES, et al. Comparison of an optical immunoassay technique with two culture methods for the detection of group A streptococci in a pediatric office. J Pediatr 1995; 126:931.
- Gerber MA, Tanz RR, Kabat W, et al. Optical immunoassay test for group A beta-hemolytic streptococcal pharyngitis. An office-based, multicenter investigation. JAMA 1997; 277:899.
- Stewart MH, Siff JE, Cydulka RK. Evaluation of the patient with sore throat, earache, and sinusitis: an evidence based approach. Emerg Med Clin North Am 1999; 17:153.
- Daly JA, Korgenski EK, Munson AC, Llausas-Magana E. Optical immunoassay for streptococcal pharyngitis: evaluation of accuracy with routine and mucoid strains associated with acute rheumatic fever outbreak in the intermountain area of the United States. J Clin Microbiol 1994; 32:531.
- Gieseker KE, Mackenzie T, Roe MH, Todd JK. Comparison of two rapid Streptococcus pyogenes diagnostic tests with a rigorous culture standard. Pediatr Infect Dis J 2002; 21:922.
- Nakhoul GN, Hickner J. Management of adults with acute streptococcal pharyngitis: minimal value for backup strep testing and overuse of antibiotics. J Gen Intern Med 2013; 28:830.
- Tanz RR, Gerber MA, Kabat W, et al. Performance of a rapid antigen-detection test and throat culture in community pediatric offices: implications for management of pharyngitis. Pediatrics 2009; 123:437.
- Humair JP, Revaz SA, Bovier P, Stalder H. Management of acute pharyngitis in adults: reliability of rapid streptococcal tests and clinical findings. Arch Intern Med 2006; 166:640.
- Cohen JF, Chalumeau M, Levy C, et al. Effect of clinical spectrum, inoculum size and physician characteristics on sensitivity of a rapid antigen detection test for group A streptococcal pharyngitis. Eur J Clin Microbiol Infect Dis 2013; 32:787.
- Dimatteo LA, Lowenstein SR, Brimhall B, et al. The relationship between the clinical features of pharyngitis and the sensitivity of a rapid antigen test: evidence of spectrum bias. Ann Emerg Med 2001; 38:648.
- Halfon ST, Davies AM, Kaplan O, et al. Primary prevention of rheumatic fever in Jerusalem schoolchildren. 2. Identification of beta-hemolytic streptococci. Isr J Med Sci 1968; 4:809.
- Chapin KC, Blake P, Wilson CD. Performance characteristics and utilization of rapid antigen test, DNA probe, and culture for detection of group a streptococci in an acute care clinic. J Clin Microbiol 2002; 40:4207.
- Carroll K, Reimer L. Microbiology and laboratory diagnosis of upper respiratory tract infections. Clin Infect Dis 1996; 23:442.
- Snellman LW, Stang HJ, Stang JM, et al. Duration of positive throat cultures for group A streptococci after initiation of antibiotic therapy. Pediatrics 1993; 91:1166.
- Gerber MA, Randolph MF, DeMeo KK. Streptococcal antigen in the pharynx after initiation of antibiotic therapy. Pediatr Infect Dis J 1987; 6:489.
- Kurtz B, Kurtz M, Roe M, Todd J. Importance of inoculum size and sampling effect in rapid antigen detection for diagnosis of Streptococcus pyogenes pharyngitis. J Clin Microbiol 2000; 38:279.
- Centor RM, Samlowski R. Avoiding sore throat morbidity and mortality: when is it not "just a sore throat?". Am Fam Physician 2011; 83:26, 28.
- Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med 2009; 151:812.
- Infectious causes
- - Group A streptococcus (GAS)
- - Viruses
- - Other bacteria
- - Mycoplasma pneumoniae
- Non-infectious causes
- CLINICAL FEATURES
- Excluding dangerous conditions
- Identifying patients with GAS
- - Centor criteria
- - Diagnostic tests
- Rapid antigen detection test
- Throat culture
- DNA probes
- Specimen collection and transport
- Patients who do not have GAS
- Patients needing further evaluation
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS