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Acute Pharyngitis in Adults: Physician Information Sheet (Adults)

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Principles apply to the diagnosis and treatment of Group A ß-hemolytic streptococcal (GABHS) pharyngitis in otherwise healthy adults.

Clinical screening for GABHS pharyngitis could substantially reduce unnecessary antibiotic use.

Background

  • Only 5-15% of adult cases of acute pharyngitis are caused by GABHS.
  • It is estimated that 3,000 to 4,000 patients with GABHS must be treated for every 1 case of acute rheumatic fever prevented.
  • Antibiotic therapy of GABHS hastens resolution by 1-2 days if initiated within 2-3 days of symptom onset.

Diagnosis

  • Lab testing is not indicated in all patients with pharyngitis. Instead, all adults should be screened for the following:
    • History of fever
    • Lack of cough
    • Tonsillar exudates
    • Tender anterior cervical adenopathy
  • Patients with none or only one of these findings should not be tested or treated for GABHS.
  • Rapid streptococcal antigen test (RAT) is recommended for patients with 2 or more criteria, with antibiotic therapy restricted to those with positive test results.
  • Cultures are not recommended for routine evaluation of adult pharyngitis or for confirmation of negative results on rapid antigen tests if test sensitivity >80%.
  • Throat cultures maybe useful for outbreak investigation, monitoring rates of antibiotic resistance, or when other pathogens (e.g., gonococcus) are being considered.

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Comparison of Diagnostic Strategies*

  Test for 2+
criteria and
treat positives
Empiric treatment for 3-4 criteria
% of patients
with GABHS who are correctly
treated
60%-70%
70%-80%
% of patients
receiving antibiotics
11%
33%

*Assumptions: RAT
sensitivity = 80%;
RAT specificity = 90%;
GABHS prevalence = 10%.

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Treatment

  • Penicillin is recommended for initial treatment of GABHS.
    • Erythromycin is recommended for penicillin-allergic patients.
    • Penicillin-resistant GABHS have not been reported in the United States.
  • Extended spectrum macrolides and fluoroquinolones are not appropriate for uncomplicated GABHS pharyngitis.

Tips to Reduce Antibiotic Use

  • Tell patients that antibiotic use increases the risk of an antibioticresistant infection.
  • Identify and validate patient concerns.
  • Recommend specific symptomatic therapy.
  • Spend time answering questions and offer a contingency plan if symptoms worsen.
  • Provide patient education materials on antibiotic resistance.
  • REMEMBER: Effective communication is more important than an antibiotic for patient satisfaction.
  • See www.cdc.gov/drugresistance/community or contact your local health department for more information and patient education materials.

Key Reference

Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal Medicine 2001;134(6):509-17.

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