An Evidence-Based Approach To The Evaluation And Treatment Of Pharyngitis In Children Abstract Sore throat is a very common complaint, accounting for approximately 7.3 million outpatient physician visits each year among children in the United States. Group A streptococcus (GAS) is the most common bacterial cause of sore throat and is responsible for 15% to 36% of cases.1 Estimated total costs attributable to GAS pharyngitis in children and adolescents are $224 million to $539 million annually, with most of these costs being attributed to parents’ lost work time.2 Pharyngitis is generally a straightforward and self-limited complaint. However, the emergency clinician must appreciate that sore throat can occasionally be a symptom of a much more serious or potentially life-threatening condition.

Case Presentation It is another busy weekend night in the ED. The next patient waiting to be seen has a chief complaint of “sore throat and fever for 5 days.” You enter the room and find a mother and her 11-year-old son. He is ill-appearing and pale but nontoxic and in no respiratory distress. His mother explains that she took the child to his usual doctor 3 days ago for evaluation of fever, sore throat, and generalized abdominal pain. A rapid strep test was done AAP Sponsor Martin I. Herman, MD, FAAP, FACEP Professor of Pediatrics, Attending Physician, Emergency Medicine Department, Sacred Heart Children’s Hospital, Pensacola, FL

December 2011

Volume 8, Number 12 Authors Jennifer Weglowski, MD, FAAP Assistant Professor of Pediatrics, University of California San Diego; Attending Physician, Division of Pediatric Emergency Medicine, Rady Children’s Hospital, San Diego, CA Peer Reviewers Derya Caglar, MD Assistant Professor of Pediatrics, University of Washington; Attending Physician, Division of Emergency Medicine Seattle Children’s Hospital, Seattle, WA Ghazala Q. Sharieff, MD, FAAP, FACEP, FAAEM Associate Clinical Professor, Children’s Hospital and Health Center/University of California; Director of Pediatric Emergency Medicine, California Emergency Physicians, San Diego, CA Paula Whiteman, MD Medical Director, Pediatric Emergency Medicine, EncinoTarzana Regional Medical Center, Tarzana, CA; Attending Physician, Cedars-Sinai Medical Center, Los Angeles, CA CME Objectives Upon completion of this article, you should be able to: 1. Cite the life-threatening causes of pharyngitis and how they may present. 2. Cite the differences in the etiologies of pharyngitis among young children versus adolescents. 3. Apply the currently recommended clinical scoring systems and testing strategies for GAS pharyngitis and evaluate how they differ when applied to young children versus adolescents. 4. Cite the appropriate treatment for GAS pharyngitis, including antibiotic therapy and supportive care. Prior to beginning this activity, see the back page for Physician CME Information.

and Dentistry of New Jersey; Pediatric Emergency Medicine Tommy Y. Kim, MD, FAAP, FACEP Director, Pediatric Emergency Division, Medical Director - Pediatric Assistant Professor of Emergency Medicine, Children’s Medical Center, Emergency Department, University Medicine and Pediatrics, Loma Atlantic Health System; Department of Florida Health Science Center Linda Medical Center and of Emergency Medicine, Morristown Jacksonville, Jacksonville, FL Children’s Hospital, Loma Memorial Hospital, Morristown, NJ Alson S. Inaba, MD, FAAP, Linda, CA

Ran D. Goldman, MD PALS-NF Editorial Board Associate Professor, Department Pediatric Emergency Medicine of Pediatrics, University of Toronto; Attending Physician, Kapiolani Jeffrey R. Avner, MD, FAAP Division of Pediatric Emergency Medical Center for Women & Professor of Clinical Pediatrics Medicine and Clinical Pharmacology Children; Associate Professor of and Chief of Pediatric Emergency and Toxicology, The Hospital for Sick Pediatrics, University of Hawaii Medicine, Albert Einstein College Children, Toronto, ON John A. Burns School of Medicine, of Medicine, Children’s Hospital at Honolulu, HI; Pediatric Advanced Montefiore, Bronx, NY Mark A. Hostetler, MD, MPH Clinical Professor of Pediatrics and Life Support National Faculty T. Kent Denmark, MD, FAAP, FACEP Representative, American Heart Emergency Medicine, University Medical Director, Medical Simulation Association, Hawaii and Pacific of Arizona Children’s Hospital Center; Associate Professor of Island Region Division of Emergency Medicine, Emergency Medicine and Pediatrics, Phoenix, AZ Andy Jagoda, MD, FACEP Loma Linda University Medical Professor and Chair, Department Center and Children’s Hospital, Madeline Matar Joseph, MD, of Emergency Medicine, Mount Loma Linda, CA FAAP, FACEP Sinai School of Medicine; Medical Associate Professor of Emergency Michael J. Gerardi, MD, FAAP, Director, Mount Sinai Hospital, New Medicine and Pediatrics, Assistant FACEP York, NY Chair for Pediatrics - Emergency Clinical Assistant Professor of Medicine Department, Chief Medicine, University of Medicine

Gary R. Strange, MD, MA, FACEP Professor and Head, Department of Emergency Medicine, University of Illinois, Chicago, IL

Christopher Strother, MD Assistant Professor, Director, Brent R. King, MD, FACEP, FAAP, Undergraduate and Emergency FAAEM Simulation, Mount Sinai School of Professor of Emergency Medicine Medicine, New York, NY and Pediatrics; Chairman, Adam Vella, MD, FAAP Department of Emergency Medicine, Assistant Professor of Emergency The University of Texas Houston Medicine, Director Of Pediatric Medical School, Houston, TX Emergency Medicine, Mount Sinai Robert Luten, MD School of Medicine, New York, NY Professor, Pediatrics and Michael Witt, MD, MPH, FACEP, Emergency Medicine, University of FAAP Florida, Jacksonville, FL Medical Director, Pediatric Ghazala Q. Sharieff, MD, FAAP, FACEP, FAAEM Associate Clinical Professor, Children’s Hospital and Health Center/University of California; Director of Pediatric Emergency Medicine, California Emergency Physicians, San Diego, CA

Emergency Medicine, Elliot Hospital Manchester, NH

Research Editor Lana Friedman, MD Fellow, Pediatric Emergency Medicine, Mount Sinai School of Medicine, New York, NY

Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Faculty Disclosure: Dr. Weglowski, Dr. Caglar, Dr. Sharieff, Dr. Whiteman, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation. Commercial Support: This issue of Pediatric Emergency Medicine Practice did not receive any commercial support.

and was “negative” per the mother’s report. Results of a throat culture are pending, but since the doctor’s office is closed for the weekend, she does not yet have them. She is very concerned because the child continues to complain of severe sore throat and is running fevers as high as 39°C (102°F). She says, “Doctor, I hope you can help us. I should have insisted that he be prescribed antibiotics while we waited for the throat culture results to come back. He’s just not getting any better!” On examination, you observe enlarged, injected tonsils with a significant amount of white exudate; enlargement of the posterior cervical lymph nodes; and a mildly tender abdomen. You remember the natural history of streptococcal pharyngitis and reply, “I don’t think that an antibiotic would have helped very much in this situation. I recommend doing some laboratory tests to confirm my suspicion.”

Introduction

Detection and appropriate treatment of GAS pharyngitis is important to avoid possible serious complications of rheumatic fever, post-streptococcal glomerulonephritis, and peritonsillar abscess. In spite of commonality, there still exists controversy about how to test for GAS pharyngitis, such as the use of rapid antigen detection testing (RADT) and the need for a throat culture. There is somewhat less contro-

Table Of Contents Abstract........................................................................ 1 Case Presentation....................................................... 1 Introduction................................................................ 2 Current Practice Guidelines..................................... 2 Critical Appraisal Of The Literature....................... 3 Epidemiology, Etiology, And Pathophysiology..... 3 Diagnosis And Treatment......................................... 4 Prehospital Care......................................................... 9 Emergency Department Evaluation...................... 10 Clinical Pathway For Evaluation Of Potentially Life-Threatening Causes Of Pharyngitis........... 12 Clinical Pathway For Evaluation Of The Child With Pharyngitis................................................... 13 Clinical Pathway For Evaluation Of The Adolescent With Pharyngitis.............................. 14 Diagnostic Studies.................................................... 16 Special Circumstances.............................................. 18 Controversies And Cutting Edge........................... 18 Risk Management Pitfalls To Avoid In The Treatment Of Pediatric Pharyngitis ........... 19 Cost-Effective Strategies ......................................... 21 Disposition................................................................ 22 Summary................................................................... 22 Case Conclusion....................................................... 22 References.................................................................. 22 CME Questions......................................................... 25 Pediatric Emergency Medicine Practice © 2011 2

versy regarding first-line antibiotic treatment of GAS pharyngitis. New organisms have emerged in recent years that have been found to cause significant sore throat, particularly in adolescents and young adults. This issue of Pediatric Emergency Medicine Practice focuses on the diagnosis and management of GAS infections and other common causes of pediatric pharyngitis as based on the best available evidence from the literature. After reading this issue, the clinician should be able to differentiate between viral and bacterial pharyngitis, recognize potentially serious or life-threatening causes of pharyngitis, and appropriately diagnose and treat GAS infections.

Current Practice Guidelines Although several guidelines have been published to help the clinician manage pharyngitis in the ambulatory setting, they differ significantly in some respects. Table 1 summarizes current practice guidelines. The American Heart Association/ American Academy of Pediatrics (AHA/AAP) guideline is the only one limited to pediatric patients. The other guidelines are adult-centered but include adolescents and patients older than 15 years of age. A review of Table 1 reveals a number of similarities between the available guidelines. For example, they all recommend that RADT or treatment not be carried out for anyone who has symptoms suggestive of viral illness, such as conjunctivitis, coryza, or cough, regardless of age. With the exception of the Centers for Disease Control and Prevention (CDC)/ American Academy of Family Physicians (AAFP)/ American College of Physicians (ACP)/American Society of Internal Medicine (ASIM) guideline,5 all the other organizations listed recommend RADT or throat culture for patients who present with symptoms suggestive of GAS infection.3,4 The CDC/ AAFP/ ACP/ASIM guideline5 relies on a scoring system6 to determine whether a patient should undergo RADT or presumptive treatment for GAS. Since the incidence of new-onset rheumatic fever in adults and older adolescents is low, the possibility of missing a case of GAS would not be as serious as in children, because the disease is typically self-limited. The potential also exists to over-treat patients with antibiotics. In fact, this has been shown to be true in adults when physicians followed the CDC guideline. Almost 50% of adults with Centor scores of 3 or 4 who were treated presumptively without RADT did not have GAS pharyngitis and were inappropriately treated with antibiotics.7 (A more detailed discussion of clinical scoring, as well as use of RADT and throat culture, can be found later in this issue under Diagnostic Studies.)

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Critical Appraisal Of The Literature

of antibiotic resistance. However, the vast majority of the pediatric literature reaches a similar conclusion with regard to the diagnosis of GAS pharyngitis and includes recommendations to perform RADT on those children with symptoms that are strongly suggestive of GAS pharyngitis, to provide appropriate treatment for those with positive results on RADT, and to perform back-up throat culture for those with negative RADT results.

The literature review included searches of PubMed, the Web of Science, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases and the Cochrane Database of Systemic Reviews for articles published between 1966 and 2011. Search terms included pharyngitis, group A beta-hemolytic streptococcus, rapid antigen detection tests, and throat culture. The results led to further, more detailed searches. The focus of the most current literature includes cost-effectiveness studies and the use of RADT with or without throat culture in the diagnosis of GAS pharyngitis. To date, no RADTs have been tested in clinical trials with a proven sensitivity greater than 90%8; thus, the test’s usefulness is limited without the additional information provided by throat culture. These results impact directly on emergency clinicians, as they often have contact with a patient only once and may be unable to reach the family if antibiotic treatment has been withheld while they await the results of a throat culture. Another area of active research is the validation of clinical scoring systems, particularly in developing areas of the world where the rates of acute rheumatic fever are high and microbiology laboratory resources (eg, RADT or throat culture) are lacking. The literature pertaining to adult patients contains spirited debate regarding the presumptive treatment of acute pharyngitis based on clinical findings alone as well as the potential for overprescribing antibiotics, which can lead to the development

Epidemiology, Etiology, And Pathophysiology As noted previously, several million cases of pharyngitis occur each year in the pediatric age group, accounting for 10% of all visits to healthcare providers.1 Whether the pharyngitis is of viral or bacterial etiology, most cases are spread via respiratory droplets and aerosol dispersion. School-aged children between the ages of 5 and 15 years are those most often affected. The vast majority of cases of pharyngitis are caused by viruses, which are the primary cause in children under 5 years of age. Group A streptococcus is the most common organism causing bacterial pharyngitis and is the only cause that is treated regularly with antibiotics. A recent metaanalysis found that 37% of children over the age of 5 years and 24% of children under the age of 5 years who presented with symptoms suggestive of GAS pharyngitis tested positive for the disease.9 Table 2

Table 1. Current Practice Guidelines3-5 Organization(s)

Age of Population

Viral Symptoms

Symptoms of GAS

Throat Culture If RADT Is Negative

Treatment

American Heart Association, endorsed by the American Academy of Pediatrics

Children

No testing or treatment

RADT or throat culture Treat only if positive

Yes

Penicillin First-generation cephalosporin or azithromycin

Infectious Diseases Society of America

Children and adolescents

No testing or treatment

RADT or throat culture Treat only if positive

Children: yes Adults: no

Penicillin Erythromycin

Centers for Disease Control, endorsed by the American Academy of Family Physicians, American College of Physicians, and American Society of Internal Medicine

Adolescents and patients older than 15 years of age

No testing or treatment

RADT based on Centor Criteria

No

Penicillin Erythromycin

Centor score = 3 or 4: RADT or treat presumptively Centor score = 2: RADT or do not test or treat Centor score = 0 or 1: No testing or treatment

Abbreviations: GAS, Group A streptococcus; RADT, rapid antigen detection test.

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shows the common pathogens that cause pharyngitis. Most of these will be discussed in more detail in the Diagnosis And Treatment section, as will other, noninfectious causes of pharyngitis.

Diagnosis And Treatment The differential diagnosis of sore throat and pharyngitis in children is broad and includes infectious, inflammatory, traumatic, irritative, allergic, and even psychogenic causes. It is the goal of the emergency clinician to differentiate between the potentially life-threatening and non–life-threatening causes and then choose the most appropriate work-up and treatment. Airway maintenance is always the first step in treating potentially life-threatening causes of pharyngitis. This might be as simple as allowing the child to choose a

Table 2. Common Pathogens Causing Acute Pharyngitis10,11 Pathogen

Symptoms or Disease

Viruses Adenovirus

Upper respiratory symptoms, conjunctivitis

Coronavirus

Upper respiratory symptoms

Rhinovirus

Upper respiratory symptoms

Enteroviruses (Coxsackie)

Gingivostomatitis, hand-footmouth disease

Herpes virus

Gingivostomatitis

Influenza A or B virus

Influenza

Parainfluenza virus

Upper respiratory symptoms, hoarseness, stridor, croup

Epstein-Barr virus

Mononucleosis

Cytomegalovirus

Mononucleosis-like illness

Human immunodeficiency virus (HIV)

Mononucleosis-like illness, adenopathy, weight loss

Bacteria Group A streptococcus

Strep throat, scarlet fever

Non–group A streptococcus (primarily groups C and G)

Pharyngitis

Fusobacterium necrophorum

Lemierre syndrome, septic thrombophlebitis of the internal jugular vein and septic emboli

Neisseria gonorrhoeae

Pharyngitis

Chlamydia pneumoniae

Respiratory illness

Mycoplasma pneumoniae

Respiratory illness, pharyngitis, headache

Arcanobacterium haemolyticum

Pharyngitis and scarlatiniform rash

Corynebacterium diphtheriae

Diphtheria, thick gray membranous exudates

Francisella tularensis

Tularemia, ulcerative pharyngitis

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position of comfort or as complicated as intubation or achieving a surgical airway via cricothyroidotomy. Intravenous hydration and pain management are useful in almost all cases. Antibiotic therapy is directed at the most likely causative agents. Treatment of non-life-threatening causes of pharyngitis usually consists of symptomatic relief. Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are useful to reduce fever and discomfort. Salt-water gargles help to debride tonsillar exudates and may offer some pain relief. Some studies have shown that the use of throat lozenges containing topical anesthetics are helpful as well.100 Oral hydration with cold or warm liquids may be soothing and also prevents dehydration. Steroids have been found to be only somewhat effective in reducing pain associated with pharyngitis in children, with the time to improvement only hours to 1 day; the most significant reduction was seen in patients with known GAS pharyngitis, but it was not found to be significant enough to recommend for routine use.12 In many studies, patients were often taking antibiotics for GAS pharyngitis and were also allowed to use acetaminophen.13 In cases of non– life-threatening pharyngitis, steroids are generally reserved for patients with severe tonsillar hypertrophy associated with infectious mononucleosis.14

Potentially Life-Threatening Causes Of Pharyngitis Epiglottitis Epiglottitis is inflammation of the epiglottis and adjacent supraglottic structures. Without treatment, epiglottitis can progress to life-threatening airway obstruction.15 After the addition of the Haemophilus influenzae type b (HIB) conjugate vaccine to the routine infant immunization schedule in the United States and other developed countries, the epidemiology of epiglottitis changed. Previously, most patients with epiglottitis were toddlers or young children; now, children diagnosed with epiglottitis tend to be older, and the number of cases among adolescents and adults has increased significantly.16-18 Currently, the annual incidence of epiglottitis among children immunized against HIB ranges from 0.60 to 0.78 cases per 100,000.19,20 The classic symptoms of epiglottitis include sore throat and fever, with rapid deterioration characterized by difficulty breathing, stridor, and a muffled voice (which, if unrecognized, may lead to airway obstruction and respiratory failure).21 As compared with its course in younger children, the disease in adolescents has been observed to progress more slowly, often developing over days rather than hours.22 In the age of widespread immunization against HIB, the most common organisms causing epiglottitis are S pneumoniae, Staphylococcus aureus, beta-hemolytic streptococcus, and nontypeable H influenzae. Third-generation cephalosporins, such as www.ebmedicine.net • December 2011

ceftriaxone and cefotaxime, as well as beta-lactamresistant penicillins, such as ampicillin/sulbactam, are most useful. Steroids are commonly used as adjuvant therapy to reduce edema and inflammation.23 Treatment of epiglottitis may include intubation.

upper airway or spread to the surrounding structures, including the masseter and pterygoid muscles and the carotid sheath, leading to potentially fatal complications of septicemia or carotid artery rupture.33 Surgical interventions for peritonsillar abscess include needle aspiration, incision and drainage, and tonsillectomy. Many patients will improve with needle aspiration and antibiotic therapy.30 Infections are usually polymicrobial and include a combination of anaerobic and aerobic organisms. Clindamycin and cephalosporins are the most commonly used antibiotics.

Retropharyngeal Abscess The retropharyngeal space extends from the base of the skull to the posterior mediastinum. The retropharyngeal space contains 2 chains of lymph nodes that are prominent in the young child but atrophy before puberty. These lymph nodes drain the nasopharynx, adenoids, posterior paranasal sinuses, middle ear, and eustachian tube. Infections in these areas may lead to suppurative adenitis of the retropharyngeal lymph nodes. The adenitis may then develop into a phlegmon and a mature abscess.24 Retropharyngeal abscesses occur most commonly in children between 2 and 4 years of age but can also be seen in older children and adolescents.25 Such cases are frequently associated with penetrating trauma to the posterior pharynx.26,27 Common presenting signs include fever, neck stiffness and pain (particularly with extension), pharyngitis, a muffled voice, decreased appetite, and drooling. There can be a significant amount of overlap between the symptoms of retropharyngeal abscess and epiglottitis. In the toddler age group, the primary difference is the more rapid onset and rate of deterioration in epiglottitis. A computed tomography (CT) scan will help differentiate retropharyngeal cellulitis from a retropharyngeal abscess. Retropharyngeal abscesses and cellulitis are also common polymicrobial infections. Treatment with broad-spectrum antibiotics, such as clindamycin and beta-lactamase-resistant cephalosporins, cover both anaerobic and aerobic organisms and may be the only treatment required.28 However, if an abscess greater than 2 cm is found on CT scan or if the patient is not improving within 48 hours of starting antibiotics, surgical drainage may be needed.29

Lemierre Syndrome In Lemierre syndrome, acute pharyngitis progresses to a more serious infection that spreads to the parapharyngeal space, leading to septic thrombophlebitis of the internal jugular vein. It is usually caused by Fusobacterium necrophorum, an anaerobic organism. More commonly seen in adolescents and adults, it presents as continued sore throat and fever that progresses to persistent fever and unilateral neck pain with stiffness and swelling. If unrecognized, the condition can lead to septic emboli, primarily to the lungs, but hepatic, renal, and joint involvement are possible. It is important to maintain a high index of suspicion, since without treatment the mortality rate can be as high as 50%.34 Many organs can be affected due to septic emboli released from the infected thrombus in the internal jugular vein. Patients frequently show signs of sepsis and often need to be managed in an intensive care unit. Antibiotic therapy is targeted at Fusobacterium spp, gram-negative anaerobes that cause up to 90% of infections. Clindamycin and metronidazole are most frequently used. Surgical drainage of a neck abscess, septic joint, or empyema may be necessary.34 Anticoagulation therapy has not been proved to be of benefit in controlled studies but may be used on a case-by-case basis.35,36 Diphtheria Since the initiation of widespread vaccination programs, diphtheria occurs only rarely in the United States. According to a 2010 global summary from the World Health Organization, the last known case in the United States was reported in 2003. However, in the early 1990s, there was a widespread outbreak of the disease in Russia and in countries of the former Soviet Union.37 The disease is more common among persons who have not been immunized and the socially disadvantaged. Corynebacterium diphtheriae is an exotoxin-producing gram-positive rod. Spread by respiratory droplets, this organism can cause severe pharyngitis, significant cervical adenopathy (“bull neck”), and the formation of a tenaciously adherent gray pseudomembrane in the pharynx, nasopharynx, or trachea. Death may re-

Peritonsillar Abscess Peritonsillar abscess is the most common deep neck infection in children and adolescents, accounting for at least 50% of cases.24,30 It occurs most frequently in adolescents and young adults but can also occur in younger children31 and may be a consequence of an antecedent pharyngeal infection or the patient’s initial presenting illness.32 Patients typically complain of unilateral throat pain, difficulty opening the mouth (trismus), and a “hot potato” or muffled voice and may have trouble swallowing. Examination findings consistent with peritonsillar abscess include an extremely swollen and fluctuant tonsil, with deviation of the uvula to the opposite side. Cervical and submandibular lymphadenopathy may be present as well. Peritonsillar infection may compromise the December 2011 • www.ebmedicine.net

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sult from respiratory obstruction or toxin-mediated sepsis and circulatory collapse.11

Non–Life-Threatening Causes Of Pharyngitis Bacterial Pharyngitis Group A Streptococcus

Group A streptococcus is the most common bacterial cause of pharyngitis in children, accounting for 15% to 36% of cases.1 As mentioned previously, children between the ages of 5 and 15 years are most commonly affected, with most cases presenting in the winter and spring. Typical symptoms include fever and sore throat of acute onset. Younger children often complain of generalized abdominal pain. The tonsils are enlarged and injected. Tonsillar exudates are usually present and can be thick or thin and of several colors, including white and gray. The anterior cervical lymph nodes are swollen and tender to palpation. Palatal petechiae may be evident. Scarlet fever is caused by erythrogenic strains of GAS that lead to a characteristic erythematous, sandpaper-like rash and sometimes a white or red “strawberry tongue.” Children under 5 years of age usually present with atypical symptoms, including prolonged nasal drainage, excoriated nares, and tender, swollen cervical lymph nodes.11 The risk of GAS infection in all age groups increases if there is a school-aged contact with GAS in the home. Without treatment, the illness is self-limited and will generally resolve on its own within 5 days. The primary rationale for treating GAS with antibiotics is to prevent suppurative complications, such as peritonsillar abscess, as well as immune-mediated complications or nonsuppurative complications, such as rheumatic fever and poststreptococcal glomerulonephritis. Rheumatic fever is quite rare in the United States, although it is still a leading cause of acquired heart disease in the developing world. Group A streptococcus is the only bacterial cause of pharyngitis that is regularly treated with antibiotics. (See Table 3.) Treatment hastens symptom relief,

decreases contagiousness, and prevents suppurative and nonsuppurative complications.38 When one is choosing an antibiotic to treat GAS pharyngitis, several factors must be kept in mind, including efficacy, ease of administration and palatability (particularly for children), cost, patient allergy, and local GAS susceptibilities. Oral penicillin V administered 2 to 3 times a day remains the first choice for treating GAS pharyngitis. A single intramuscular dose of penicillin G may be given if patient adherence is an issue, if the patient is vomiting and unable to tolerate oral intake, or in low-resource settings where patients may not have access to the prescribed medication. There has never been a documented case of GAS resistance to penicillin, and it has a very narrow spectrum of activity and is inexpensive.3 A recent Cochrane review cites these reasons and found that there is no strong evidence to recommend anything but penicillin as first-line treatment for GAS pharyngitis.39 The recommended course of treatment with penicillin is 10 days; however, another recent Cochrane review found that in areas where the incidence of acute rheumatic fever is low, 3- to 6-day courses of penicillin are just as effective.40 The reportedly higher number of “treatment failures” after a course of penicillin V versus a first-generation cephalosporin is thought to be more likely the result of GAS carriage in the pharynx than of true infection.41 The disadvantage of penicillin in treating children with GAS is its unpleasant taste, which can make it difficult to administer and lead to decreased adherence. Amoxicillin has been shown to be an adequate substitute and is far more palatable. An additional benefit is that amoxicillin given once a day has been shown in several studies to be as effective as twice-daily penicillin V.42,43 For penicillin-allergic patients, the Infectious Diseases Society of America and the CDC/AAFP/ACP/ASIM guideline recommends erythromycin, a first-generation cephalosporin (cephalexin or cefadroxil), or, in the rare case of an erythromycin-resistant strain of GAS in a patient who is also allergic to penicillin, clindamycin.4,5

Table 3. Current Recommended Antibiotic Treatment For Group A Streptococcus Pharyngitis59 Medication

Dose

Duration

Penicillin V

Children < 27 kg: 250 mg PO 2 or 3 times a day Children > 27 kg and adolescents: 500 mg PO 2 or 3 times a day

10 days

Amoxicillin

50 mg/kg/day PO daily (maximum 1 g/day)

10 days

Benzathine/penicillin G

Children < 27 kg: 600,000 units IM Children > 27 kg: 1,200,000 units IM

One time only

First-generation cephalosporin (cephalexin or cefadroxil)

Dose varies depending on agent chosen

10 days

Azithromycin

12 mg/kg PO daily (maximum 500 mg/day)

5 days

Clindamycin

20 mg/kg/day PO divided into 3 doses (maximum 1.8 g/day)

10 days

Abbreviations: IM, intramuscularly; PO, by mouth.

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The most current AHA/AAP guideline no longer lists erythromycin on the list of preferred antibiotics to treat GAS, although this drug is discussed in the body of the guideline.3 Erythromycin typically is given 4 times a day and is commonly associated with diarrhea and other gastrointestinal upset, making it an unattractive treatment option. Other macrolides, such as azithromycin and clarithromycin, may be used instead of erythromycin. The first-generation cephalosporins (eg, cephalexin and cefadroxil) are also excellent choices, as long as there is no history of immediate or type 1 hypersensitivity reactions to penicillins because of the small chance of cross-reactivity. Children who chronically and asymptomatically carry GAS in the pharynx generally do not need to be treated other than in the rare instance when a close contact has a history of rheumatic fever or rheumatic heart disease, they live in a closed community or institution, or there is a community outbreak of rheumatic fever. Treatment includes clindamycin or benzathine penicillin G/amoxicillin/ cephalosporin plus rifampin.44 There are no specific recommendations for empirically treating children for GAS without first performing RADT or obtaining a BAP throat culture. However, a recent review noted that, in some specific situations, there is “sufficient clinical and epidemiological evidence that antimicrobial therapy can be initiated while awaiting laboratory confirmation, provided that such therapy is discontinued if the diagnosis of GAS is not confirmed by a laboratory test.”45 These include the presence of a scarlatiniform rash, a current diagnosis of rheumatic fever, or a past history of rheumatic fever.45

throat culture in most facilities and is therefore often not identified. Infection with A haemolyticum should be suspected in an adolescent with pharyngitis and a scarlatiniform rash with a negative RADT and throat culture. Treatment with erythromycin is preferred owing to reports of penicillin failure.50 Neisseria gonorrhoeae

Pharyngitis caused by N gonorrhoeae is relatively uncommon, with symptoms and findings on physical examination similar to those seen in GAS pharyngitis, including tonsillar exudates, pain on swallowing, and tender anterior cervical lymphadenopathy.51 It is more common in sexually active adolescents who engage in fellatio and is a possible sign of sexual abuse if diagnosed in a child.52 If infection with N gonorrhoeae is suspected, throat swab specimens must be incubated on Thayer-Martin medium. The preferred treatment is a single dose of intramuscular ceftriaxone.50 Mycoplasma pneumoniae And Chlamydia pneumoniae

M pneumoniae is a common cause of respiratory illness and pneumonia in school-aged children. Pharyngitis and headache are two of the most common complaints of patients with this infection. The presence of a cough is a clinical clue that the symptoms are not due to GAS. C pneumoniae infections are clinically indistinguishable from those caused by M pneumoniae and have been seen in children in all age groups. The preferred treatment of either infection is azithromycin.53 Francisella tularensis

Pharyngitis is one of several clinical syndromes that can be associated with F tularensis infection. Infection usually results from eating under-cooked wild game or drinking contaminated water. The tonsillar exudates seen on examination may mimic the pseudomembrane seen in diphtheria. A high index of suspicion must be maintained in endemic areas, since the organism will not grow on the usual throat culture media. Treatment is with gentamycin.54

Groups C And G Streptococcus

Infection with these strains of streptococcus can cause pharyngitis with symptoms similar to those caused by GAS but usually less severe in nature. There have been well-documented outbreaks of food-borne pharyngitis caused by both groups.11 Group C is a relatively common cause of pharyngitis among college students.46 Since neither strain is known to cause rheumatic fever, it is generally acceptable to offer symptomatic treatment because, as with GAS infection, the course is usually selflimited. Antibiotic treatment may be offered to patients with more severe disease or to those who do not respond to symptomatic treatment alone.47

Viral Pharyngitis Rhinovirus And Coronavirus

Both these viruses are causes of the common cold. Although pharyngitis is often a symptom of infection, coryza and cough are also prominent features, which should indicate to the clinician that the patient’s sore throat is probably not due to GAS infection. Symptomatic treatment and adequate oral hydration are typically all that are required for these self-limited infections.

Arcanobacterium haemolyticum

Infection with this organism can cause symptoms indistinguishable from those caused by GAS and can result in a scarlatiniform rash.48 It is uncommon and appears to have a higher incidence among adolescents.49 A haemolyticum is a slow-growing organism on the sheep’s blood agar plates (BAPs) used for December 2011 • www.ebmedicine.net

Adenovirus

The most common presentation of adenovirus infection includes pharyngitis, coryza, and fever. Pharyn7

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goconjunctival fever is a clinically distinct syndrome caused by a specific serotype of adenovirus that is characterized by high fever (> 39°C [102.2°F]), pharyngitis with or without tonsillar exudates, nonpurulent conjunctivitis, rhinitis, and preauricular and cervical adenopathy.55 Adenoviral infections can mimic serious bacterial infections with high fevers, leukocytosis, elevated erythrocyte sedimentation rate, and elevated C-reactive protein levels.56 Most infections require only symptomatic treatment. Parainfluenza

Parainfluenza infections cause a variety of upper and lower respiratory illnesses. Common upper respiratory infections include croup and laryngotracheitis. Pharyngitis is usually accompanied by a hoarse voice, inspiratory stridor, and a barking cough. Respiratory distress or failure may be seen in severe infections owing to edema of the upper airway. Severe illness may also mimic lifethreatening bacterial infections such as epiglottitis or bacterial tracheitis. Mild to moderate illness can usually be managed with humidified air, oral or intramuscular steroid, aerosolized epinephrine, and adequate hydration.57 Influenza A And B

Pharyngitis is one of many symptoms associated with influenza infection. Fever, cough, coryza, myalgias, headache, and vomiting are commonly associated with influenza. Symptomatic care is the mainstay of treatment, along with the use of an antiviral medication such as oseltamivir. Coxsackie Virus

A member of the enterovirus genus, coxsackie virus is a common cause of febrile illness in the summer and fall. Hand-foot-mouth disease is caused primarily by coxsackie virus A16, which manifests as pharyngitis and vesicular lesions of the soft palate and posterior pharynx as well as a vesicular rash primarily on the hands and feet that may also be seen on the buttocks.58 Treatment is supportive, with attempts to avoid the common complication of dehydration by minimizing mouth pain. Herpes Virus

The most common manifestation of primary herpes simplex virus type 1 (HSV-1) infection is gingivostomatitis, along with exudative or nonexudative pharyngitis, vesicular oral lesions in all areas of the mouth (including the lips), gingival inflammation, bleeding and edema, cervical adenopathy, and high fever.59 As in coxsackie virus infection, dehydration is the primary complication owing to decreased oral intake. A 1993 study found that herpes simplex virus caused pharyngitis in 5.7% of 613 college students who presented to a student health clinic with sore throat. More than half the subjects did not have oral Pediatric Emergency Medicine Practice © 2011 8

lesions.60 In a randomized double-blind placebocontrolled study, oral acyclovir begun within the first 3 days of illness was shown to shorten the duration of illness.61 Human Immunodeficiency Virus

Primary infection with human immunodeficiency virus (HIV) is often marked by the “acute retroviral syndrome,” which occurs within days to weeks after the primary infection and is characterized by complaints of high fever of acute onset, nonexudative pharyngitis, lymphadenopathy, malaise, rash, and diarrhea.62,63 In patients at high risk, HIV infection must be included in the differential diagnosis of pharyngitis that is accompanied by other “mono-like” symptoms, along with other illnesses that cause similar symptoms (including EpsteinBarr virus, cytomegalovirus, human herpes virus 6, hepatitis A, and Toxoplasma gondii infections).64 Infectious Mononucleosis

Most commonly associated with Epstein-Barr virus, infectious mononucleosis is a common infection, particularly in teens and young adults, although it is frequently diagnosed in younger children as well. It should be considered in patients who have fever and symptoms that last longer than those of a typical GAS infection. Classically, there is fever of slow onset (over days) (39°C-40°C [102.2°F-104°F]), severe sore throat, and cervical lymphadenopathy (anterior or posterior). In young children, periorbital edema is more frequently seen. Teens and young adults more often complain of extreme fatigue and malaise. Hepatomegaly and splenomegaly are possible findings. The pharyngitis associated with mononucleosis is often exudative and can be accompanied by significant edema of the tonsils, potentially leading to airway obstruction. The finding of exudative pharyngitis and fever may lead the clinician to suspect and clinically diagnose GAS pharyngitis. Although it has been reported that up to 30% of patients may have co-infection with GAS, a positive result on RADT may also indicate coincidental carriage of the organism. Treatment with amoxicillin or ampicillin can lead to a pruritic, erythematous, morbilliform rash covering approximately 95% of the body, which can be distressing to the patient and their family. Diagnosis is usually made based on clinical features and laboratory studies, including a complete blood count (CBC) with differential, heterophile antibody screen, or “monospot” test or on specific testing for antibodies against Epstein-Barr virus. Liver enzymes may also show modest elevations. The CBC usually reveals lymphocytosis (greater than 50%) and atypical lymphocytes. In one study, the finding of more than 10% atypical lymphocytes on a peripheral smear had a sensitivity of 75% and a specificity of 92% for a diagnosis of mononucleosis.65 Mild www.ebmedicine.net • December 2011

thrombocytopenia is also a common finding. Heterophile antibody rapid tests for mononucleosis are often negative in the first week of illness and have been found to be much less sensitive in children under 12 years of age.66 In cases of severe illness or illness in a young child, it is appropriate to test for Epstein-Barr virus–specific antibodies to confirm the diagnosis. The illness is usually self-limited and lasts for 2 to 3 weeks. Treatment of infectious mononucleosis includes rest, adequate hydration and antipyretics and anti-inflammatory medications for pain (acetaminophen or ibuprofen). Some clinicians have advocated the use of steroids for symptom control, but a recent Cochrane review found insufficient evidence to recommend this.67 Steroid treatment should be reserved for patients with severe tonsillar hypertrophy with signs of impending upper airway obstruction.

The diagnosis of thrush in an older child is less common and should suggest possible immune deficiency or HIV infection.70 Allergic Rhinitis

In addition to complaining of a sore throat that is often described as “dry” or “scratchy,” patients with allergic rhinitis will often have rhinorrhea, cough, and itchy, watery eyes. Fever is not associated with allergic rhinitis. Foreign-Body Aspiration Or Ingestion

Noninfectious Causes Of Pharyngitis In addition to infectious causes of pharyngitis, there are a number of noninfectious etiologies to keep in mind.

Ingestion or aspiration of small objects, such as fish bones, may not be apparent after an initial choking episode. Sharp objects may become embedded in the soft tissue of the posterior pharynx and lead to symptoms of sore throat, cough, hoarseness, or difficulty breathing. Foreign bodies may puncture the posterior pharynx or soft palate, leading to serious infections and possible injury to surrounding deep neck structures.26 Removal of visible foreign bodies from a child’s pharynx is generally best left to a subspecialist in a controlled environment.

Kawasaki Disease

Inhalation Exposure

Also known as mucocutaneous lymph node syndrome, Kawasaki disease is a self-limited acute vasculitis of unknown etiology that affects primarily infants and young children. It is mentioned in the differential diagnosis of pharyngitis, since patients with Kawasaki disease may have signs and symptoms that overlap with those of other more common causes of pharyngitis, such as fever, sore throat, pharyngeal injection, strawberry tongue, rash, and cervical lymphadenopathy. Patients with this disease will often have other findings that help the clinician differentiate Kawasaki disease from other causes of pharyngitis, such as a protracted fever (5 days or more); red eyes without discharge; dry, cracked, red lips; and swelling and redness of the hands or feet. The primary reason to diagnose and treat Kawasaki disease is to avoid the formation of coronary artery aneurysms. All patients diagnosed with this disease should have an echocardiogram to screen for the presence of coronary artery aneurysms.68 Treatment consists of intravenous immune globulin (IVIG) and high-dose aspirin.

Exposure to noxious fumes or smoke may lead to pharyngeal irritation and sore throat. It is often accompanied by cough and eye irritation. Gastroesophageal Reflux Disease

Persistent or intermittent reflux of acidic gastric contents may lead to pharyngitis that is often accompanied by cough and chest discomfort. Pain is most frequently present after meals and when the person is in the supine position. Psychogenic Pharyngitis

After a choking spell, patients may complain of dysphagia, sore throat, or a persistent foreign-body sensation, referred to as globus.

Prehospital Care For the majority of patients with pharyngitis who present to the ED, prehospital care is limited to prior efforts at home to reduce fever and pain. However, in those cases of pharyngitis due to potentially lifethreatening causes, such as epiglottitis, following the standard Basic Life Support/Pediatric Advanced Life Support (BLS/PALS) protocol — maintenance of airway patency, breathing, and circulation — is paramount. Patients with significant respiratory distress, air hunger, anxiety, stridor, drooling, or dysphonia should be allowed to maintain a position of comfort, preferably on the parent’s lap for young children, with a minimum of manipulation, since crying can acutely worsen symptoms and lead to total airway obstruction. Supplemental oxygen should be deliv-

Thrush

A common condition in newborns and infants, the fungal infection known as thrush can present with decreased appetite or refusal to eat, leading a caretaker to believe that the child has a sore throat. Examination of the mouth and pharynx reveals tenacious white plaques on the tongue, buccal mucosa, hard and soft palates, and perhaps the posterior pharynx, with surrounding erythema.69 Candidal diaper dermatitis may be present as well. December 2011 • www.ebmedicine.net

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ered in the least irritating manner possible, such as a blow-by or parent-held mask. For children who are in frank respiratory failure, oxygenation via bag-valvemask should be initiated immediately. High pressures may be necessary if the airway is obstructed. Since significant airway edema may be present, intubation may be technically challenging and is best done in a controlled environment with support from an otolaryngologist or anesthetist. Peripheral placement of an intravenous (IV) line is recommended if the child has signs and symptoms of dehydration but should be avoided if the child is in significant respiratory distress and would become too upset.

Emergency Department Evaluation The primary goal of the emergency department (ED) evaluation is to determine whether the patient has a life-threatening or non-life-threatening cause of pharyngitis. A thorough history and physical examination are the keys to making this determination. Keeping in mind the epidemiology and seasonality of certain diseases will also assist in making the proper diagnosis. For example, GAS infections are most common in children 5 to 15 years of age and are more common in the winter and spring. Mononucleosis is more common in adolescents and young adults. Coxsackie virus infection is typically seen in younger children in the summer and fall.

Important Questions On History

How long have the symptoms been present? In the majority of cases, sore throat of viral or bacterial cause is self-limited, with a course of 3 to 5 days. Sore throat that persists beyond 5 days warrants further investigation and should prompt the clinician to broaden the differential diagnosis. Was the onset acute, or has there been a gradual worsening of pain? Again, most cases of sore throat caused by viruses or bacteria present acutely, whereas a sore throat that has progressively worsened over time is more likely due to a more serious condition, such as a peritonsillar abscess, retropharyngeal abscess, or Lemierre syndrome. Where is the pain? Localizing the pain can be useful. Older children and adolescents should be able to describe the pain as unilateral or more generalized and indicate which area hurts the most. Unilateral throat pain suggests peritonsillar abscess, a retained foreign body, or cervical adenitis. Was there a preceding choking spell or exposure to smoke or other chemical? This information can be very helpful in either aiding in the diagnosis or guiding the work-up. Are there ill contacts with similar symptoms? School-aged contacts with GAS pharyngitis can spread the illness to their younger siblings, even infants and toddlers. Children at camp or college Pediatric Emergency Medicine Practice © 2011 10

students living in dormitories can be sources of infection with enterovirus, infectious mononucleosis, and non-GAS pharyngitis. Is there a significant past medical history? Gastroesophageal reflux disease (GERD), allergic rhinitis, chronic sinusitis, snoring, or sleep apnea may all lead to symptoms of pharyngitis. Of note, these conditions are not usually associated with actual painful swallowing (odynophagia) and usually are not constantly present throughout the day. Patients with GERD will have more symptoms after eating a meal, whereas those with allergic rhinitis will have more discomfort in the morning owing to mouth-breathing during sleep.28 Although rheumatic fever or rheumatic heart disease is quite rare in the developed world, it is important to ask whether the patient has such a history. Is there a significant past surgical history? Recent dental work, such as root canal surgery or oral piercing, increases the risk of oropharyngeal infection. Is the patient sexually active? It is critical to directly question adolescents about any sexual activity, since sexual activity increases the risk of pharyngitis due to N gonorrhoeae, herpes virus, or HIV infection and can assist in guiding the work-up if more common etiologies of pharyngitis are not found. What treatment was administered prior to arrival in the ED? Assessing the patient’s home treatment will assist in formulating a care plan upon discharge. If acetaminophen or ibuprofen has not been effective in treating the patient’s pain at home, a stronger analgesic may be required. It is also important to ask whether the patient has taken an antibiotic prior to arrival. Often people will save pills left over from old, unfinished prescriptions. Most GAS-positive throat cultures will clear within 24 hours of the start of antibiotic therapy, possibly altering the choice of further tests. What other associated symptoms are present? Fever, respiratory symptoms, changes in the voice, and other complaints may also signal pharyngitis in the pediatric patient. Fever Fever is a hallmark of an infectious or inflammatory process and is often present in a variety of viral and bacterial conditions. The height of the fever, although not specific to any particular disease, can sometimes be helpful for guiding the workup, particularly in older children and adolescents who typically do not mount as vigorous a febrile immune response to infection as do toddlers and younger children. Fever, of greater than 39°C [102.2°F) in an older child or adolescent should prompt the clinician to consider bacterial causes of pharyngitis such as peritonsillar abscess, Lemierre syndrome, or a GAS infection. Fevers greater than 40°C (104°F) in younger children may indiwww.ebmedicine.net • December 2011

cate a bacterial infection and sepsis, prompting the consideration of retropharyngeal abscess or epiglottitis, depending on what other symptoms are present. Keep in mind that viral infections can lead to high fevers as well, particularly those due to influenza, coxsackie virus, Epstein-Barr virus, and herpes virus. The duration of a fever is also an important consideration, since a fever persisting longer than 4 to 5 days should prompt further investigation into other causes of pharyngitis beyond viral or GAS, such as infectious mononucleosis, Kawasaki disease, or cervical adenitis.

occur simultaneously with taking the history and performing a focused physical examination. Vital Signs Review of the vital signs is essential and can also reveal much about the patient’s condition before the actual examination. Fever indicates a likely infectious cause of pharyngitis. An elevated pulse may be due to fever or pain or may indicate that the patient is compensating for dehydration. Elevated blood pressure may be due to anxiety or pain; a low blood pressure suggests severe dehydration or sepsis. The respiratory rate may be increased because of fever, infection (eg, pneumonia), or partial airway obstruction. Decreased oxygen saturation suggests lung disease, sepsis, or impending respiratory failure.

Respiratory Symptoms Respiratory symptoms can range from nasal congestion and cough to acute respiratory distress. At the less severe end of the spectrum, nasal congestion and cough may be due to viral or M pneumoniae infection or allergic rhinitis. Respiratory distress marked by stridor, increased work of breathing, cyanosis, or refusal to recline should immediately suggest potentially life-threatening causes of pharyngitis such as epiglottitis, retropharyngeal abscess, parapharyngeal abscess, severe croup, or extreme tonsillar hypertrophy due to infectious mononucleosis.

Eyes Frequently, a febrile patient will have hyperemic conjunctivae owing to peripheral blood vessel dilatation. Injected conjunctivae with purulent or mucoid drainage indicate a likely viral cause of pharyngitis. Edema of the eyelids without conjunctival injection or drainage can be seen in infectious mononucleosis, particularly in younger children. Injected conjunctivae with sparing of the limbus and no drainage in the setting of fever present for more than 5 days suggest Kawasaki disease.

Voice Changes Voice changes are associated with different causes of pharyngitis. Hoarseness can be seen with viral croup or laryngitis due to inflammation of the glottis and vocal cords. A muffled or “hot potato” voice is frequently observed in patients with peritonsillar abscess or with significant tonsillar hypertrophy due to infectious mononucleosis or GAS infection.

Nose Clear, mucoid, or purulent rhinorrhea is seen with viral illness or acute sinusitis. Pale, edematous turbinates with rhinorrhea suggest allergic rhinitis. Mouth And Throat Drooling

Other Complaints Headache, generalized abdominal pain, nausea, and vomiting are often associated with GAS infections, particularly in younger children. Headache and diarrhea are often complaints with adenovirus and coxsackie virus infections. Eye redness and drainage is also seen with adenovirus or other viral illnesses, and redness without drainage is observed in Kawasaki disease. Rash can be associated with many causes of pharyngitis, including GAS, coxsackie virus, EpsteinBarr virus, and A haemolyticum infections.

Drooling, often the result of severe pain on swallowing or obstruction of the throat due to enlarged tonsils or another type of obstruction, is usually an ominous sign. Patients who are drooling are usually significantly dehydrated and require careful monitoring. Edema

Edema can be present as a generalized swelling of the posterior pharynx or tonsils in pharyngitis caused by a viral or bacterial infection. Of greater concern is the finding of unilateral tonsillar or soft palate edema, which is a common finding in peritonsillar abscess or cellulitis. The uvula may be edematous in cases of uvulitis, usually caused by nontypeable H influenza, or may be deviated toward the unaffected side in a patient with peritonsillar abscess. Elevation of the tongue or firm swelling on the floor of the mouth, particularly in the setting of recent dental work, suggests Ludwig angina, an anaerobic infection of the mouth and neck. Edema of the tongue and lips in addition to pharyngeal edema should raise concern about a possible anaphylactic allergic reaction.

Physical Examination General Appearance The patient’s appearance is the most immediate and often the most telling aspect of the physical examination. Before a hand is laid on the patient, a rapid general assessment will alert the clinician as to how ill the patient is. If the patient is sitting quietly on the parent’s lap and smiling, the chances of there being a life-threatening cause of pharyngitis is much lower than if the patient appears anxious and air hungry, is drooling, and refuses to lie down. In such situations, stabilization and preparation for resuscitation may December 2011 • www.ebmedicine.net

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Clinical Pathway For Evaluation Of Potentially Life-Threatening Causes Of Pharyngitis Assess airway and respiratory status

Is there evidence of airway obstruction?

YES

NO

Is there evidence of dehydration?

YES

NO

Is drooling, stridor, or fever present?

YES

NO

Is neck pain, decreased ROM, or fever present?

YES

NO

Are any of the following present? Muffled voice Unilateral neck pain Unilateral tonsillar enlargement Uvular deviation

YES

NO

Is the patient feverish, toxic-appearing, suffering from unilateral neck pain, or adolescent?

YES

NO

Does the patient have tonsillar exudates, swollen tonsils, or difficulty breathing when supine?

YES

Perform PALS resuscitation. Consider specialty consultation if difficult airway is anticipated. (Class I)

Insert a peripheral IV if patient is not in danger of acute airway obstruction. (Class II)

Consider epiglottitis. Maintain patient’s position of comfort. Arrange an ENT consultation to directly inspect epiglottis in OR. (Class I)

Consider retropharyngeal abscess. Order lateral neck x-ray or CT with contrast. Utilize IV hydration and antibiotics. (Class I)

Consider peritonsillar abscess. Utilize IV hydration and needle aspiration. (Class II) Utilize IV or oral antibiotics and order ENT consultation for Possible I&D (Class I)

Consider Lemierre syndrome. Utilize IV antibiotics and hydration. Order CT of the neck with contrast to evaluate for jugular venous thrombus. (Class I)

Consider mononucleosis with upper airway obstruction. Order IV hydration, with dexamethasone 0.3 mg/kg IV and mononucleosis spot test. (Class II)

Abbreviations: CT, computed tomography; ENT, ear, nose, throat; I&D, incision and drainage; IV, intravenous; OR, operating room; PALS, pediatric advanced life support; ROM, range of motion. For class of evidence definitions, see page 26.

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Clinical Pathway For Evaluation Of The Child With Pharyngitis

Assess airway and respiratory status

Is there evidence of airway obstruction?

YES

Perform PALS resuscitation. Consider specialty consultation if difficult airway is anticipated. (Class I)

NO

Is there evidence of dehydration?

YES

Order adequate analgesia with peripheral or oral hydration. (Class I)

NO

Perform history and physical examination

Are upper respiratory infection symptoms present?

YES

NO

All modified Centor criteria met?

Do not perform RADT or throat culture. Do not treat with antibiotics. Practice symptomatic care. (Class II)

Perform RADT Is RADT positive? (Class I)

YES

NO Modified Centor criteria 1. Age between 5 and 15 years 2. Fever 3. Absence of cough 4. Tonsillar exudates 5. Tender anterior cervical lymphadenopathy

NO

YES

Perform throat culture. Obtain contact information. (Class I)

Treat with appropriate antibiotic. (Class I)

Some modified Centor criteria met?

YES

Perform RADT or throat culture alone. (Class II) Is RADT or culture positive? NO

NO

YES

Consider alternate diagnosis

Consider alternate diagnosis.

Treat with appropriate antibiotic. (Class I) Abbreviations: PALS, pediatric advanced life support; RADT, rapid antigen detection test. For class of evidence definitions, see page 26.

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Clinical Pathway For Evaluation Of The Adolescent With Pharyngitis

Assess airway and respiratory status

Is there evidence of airway obstruction?

YES

Perform PALS resuscitation. Consider specialty consultation if difficult airway is anticipated. (Class I)

NO

Is there evidence of dehydration?

YES

Order adequate analgesia and peripheral or oral hydration. (Class I)

NO

Perform history and physical examination.

Are upper respiratory infection symptoms present?

YES

NO

Are 3 or 4 Centor criteria present?

Do not perform RADT or throat culture. Do not treat with antibiotics. Perform symptomatic care. (Class I)

Empiric treatment. Do not test. (Class II)

YES

NO

Are 2 Centor criteria present? NO

Perform RADT Is RADT positive? (Class I)

YES

Centor Criteria 1. Fever 2. Lack of cough 3. Tender cervical lymphadenopathy 4. Tonsillar exudates

NO

YES

No throat culture and no treatment. (Class II)

Treat with appropriate antibiotic. (Class I)

Is 1 Centor criteria present?

YES

Do not test and do not treat. Consider alternate diagnosis. (Class II)

NO

Consider alternate diagnosis. Abbreviation: RADT, rapid antigen detection test. For class of evidence definitions, see page 26.

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tious process like Kawasaki disease. Patients with a retropharyngeal abscess often complain of neck pain and are unable to fully extend the neck owing to pain. Situations in which sick-appearing children present with a high fever, neck pain, and a decreased range of neck motion raise concern about possible meningitis, and these findings may require lumbar puncture for an accurate diagnosis.

Trismus

Trismus, or the inability to open the mouth fully without pain, is commonly seen in patients with peritonsillar abscess. Inflammation of the pterygoid muscle leads to pain and can make complete examination of the pharynx difficult. Tonsillar Enlargement And Injection

Large tonsils can be observed with a variety of conditions that cause pharyngitis, including viral illness, GAS and non-GAS bacterial infections, and allergic rhinitis. The presence of redness or injection of the tonsils is more indicative of an infectious process but is not specific for either a viral or a bacterial cause.

Lungs Stridor, caused by upper airway edema in the area of the glottis, is a common finding in patients with croup but may also be associated with more serious conditions such as epiglottitis or foreign-body aspiration. Signs of respiratory distress include an increased respiratory rate and increased work of breathing marked by nasal flaring, use of accessory muscles, suprasternal or intercostal retractions, or grunting. In severe cases, the patient may appear anxious or air hungry, which requires an immediate response to secure the airway. Other lung findings might include rales, wheezing, or rhonchi in cases of pharyngitis associated with viral illness or atypical bacterial infections such as M pneumoniae or C pneumoniae.

Tonsillar Exudates

Exudates can be described as thick or thin and range in color from white to yellow to gray or may even be bloody. Group A streptococcus infection is associated with thick tonsillar exudates. Tonsillar exudates are also commonly seen with infectious mononucleosis and can be significant. Although quite uncommon in the developed world, C diphtheriae infection classically presents with the formation of a thin, gray pseudomembrane that can cover the pharynx and tonsils and may lead to airway compromise.

Abdomen Generalized abdominal tenderness on palpation may be evident in GAS pharyngitis. An enlarged and tender spleen can be seen in up to 65% of cases of infectious mononucleosis.66 Hepatomegaly is less common.

Vesicles And Ulcers

Ulcerative lesions are commonly seen in coxsackie virus infection. Usually found on the soft palate and posterior pharynx, the lesions start as vesicles that eventually slough, leaving 4-mm to 8-mm ulcers with surrounding rings of erythema. Gingivostomatitis caused by herpes virus also causes vesicle and ulcer formation that typically involves the entire oropharynx as well as the lips and perioral area. In endemic areas, F tularensis infection may also lead to an ulcerative pharyngitis.

Lymphadenopathy Cervical lymphadenopathy was discussed previously. More widespread lymphadenopathy (eg, axillary or inguinal) can be seen in infectious mononucleosis and HIV infection. Skin Rashes can be observed with many of the illnesses that cause pharyngitis. Scarlet fever is caused by a GAS subtype that produces an erythrogenic toxin. This leads to the usual features of GAS infection but also the appearance of an erythematous, sandpaper-like rash all over the body that is more pronounced in the axillae and groin. It typically spares the circumoral area, leaving an area of apparent pallor. After a few days of illness, the rash begins to peel, particularly on the palms and soles. Infectious mononucleosis sometimes presents with a pink, nondescript maculopapular eruption, but more commonly known is the erythematous wholebody maculopapular eruption that occurs if a patient with infectious mononucleosis is treated with ampicillin or amoxicillin. Coxsackie virus causes an erythematous papular, vesicular, or pustular eruption on the hands, feet, and buttocks in addition to

Petechiae

Palatal petechiae are often seen with GAS infections and are occasionally seen in patients with infectious mononucleosis. If purpura is observed in the mouth or if petechiae are found on other areas of the body, it is essential to consider possible hematologic, septic, or oncologic causes. Neck Cervical lymphadenopathy is a frequent finding in patients with pharyngitis. Tender, anterior cervical lymphadenopathy is commonly seen with GAS infections. Significant enlargement of the cervical lymph nodes can be seen with diphtheria infection, leading to the finding of a “bull neck.” Posterior as well as anterior lymphadenopathy is common with infectious mononucleosis. Unilateral neck swelling or pain suggests a serious infection, such as peritonsillar abscess, cervical adenitis, or a noninfecDecember 2011 • www.ebmedicine.net

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mouth sores. A haemolyticum infection often leads to a scarlatiniform rash that does not peel.50 Nondescript rashes have been observed in the acute retroviral syndrome of HIV infection as well as in many other viral illnesses.

Diagnostic Studies Diagnostic testing, if needed at all, is based initially on whether the patient is presumed to have a lifethreatening cause of pharyngitis. Diagnostic studies are then chosen based primarily on how stable the patient is and whether he or she can tolerate a change in position or the discomfort associated with the testing. Plain radiographs of the neck can be helpful if one suspects a retropharyngeal abscess, foreign-body aspiration/ingestion, or epiglottitis. A lateral view of the neck in an extended position will show edema of the prevertebral soft tissue or free air in the posterior pharyngeal soft tissue in the case of abscess. To determine whether the swelling is severe, assess the width of the prevertebral soft tissue; if it is greater than one-half the width of the corresponding vertebra, it is considered significant.71 The lateral neck film may also reveal the presence of a foreign body and whether it is radio-opaque, and it can also demonstrate the presence of an enlarged epiglottis, known as the “thumbprint sign.” A highkilovolt radiograph will magnify the upper airway and can be useful in identifying supraglottic narrowing or the “steeple sign” seen with epiglottitis. If the lateral neck film suggests a retropharyngeal abscess or if there is concern for other deep neck infections, such as Lemierre syndrome or an abscessed cervical lymph node, computed tomography (CT) of the neck with IV contrast is indicated to determine the exact location of the infection and whether there is true abscess formation, as opposed to cellulitis or phlegmon. These findings drive treatment, whether surgical or medical. Blood tests such as a CBC with differential are useful to determine whether an infection is most likely bacterial or viral, as based on the total white blood cell (WBC) count and the presence of bands. Blood culture, if positive, is useful for directing antibiotic therapy. For patients with an apparently non-life-threatening cause of pharyngitis, the history and physical examination will determine what, if any, diagnostic testing is needed. The only bacterial cause of pharyngitis that is regularly diagnosed and treated with antibiotics is GAS. As mentioned earlier, the primary rationale for treating GAS pharyngitis is to avoid suppurative complications, such as peritonsillar abscess, retropharyngeal abscess, otitis media, and sinusitis, as well as nonsuppurative complications such as acute rheumatic fever or poststreptococcal glomerulonephritis. A recent Cochrane review of the use of antibiotics to treat sore throat found Pediatric Emergency Medicine Practice © 2011 16

good evidence to support both rationales.72 The same review found that treatment of GAS pharyngitis with antibiotics also decreased the duration of the illness by about 24 hours. Decreased infectivity toward others is yet another reason to treat GAS pharyngitis, since the organism is not usually present on throat culture about 24 hours after starting treatment —meaning that the patient can return to school or work sooner.73 The diagnostic studies most commonly used in the ED setting are RADTs and throat culture on a BAP. In the pediatric setting, the most convenient way to obtain the sample is with a two-headed swab vigorously rubbed over the tonsils and posterior pharynx. Since it is crucial to avoid sampling the tongue and buccal mucosa, it is best to request that the parents, even those of school-aged children, hold the child securely against them, facing the practitioner, so that the sample can be obtained in a quick and efficacious manner.

Rapid Antigen Detection Testing

Rapid antigen detection testing was introduced in the 1980s to address the delays in diagnosis with traditional throat culture, the results of which are typically not available until 24 to 48 hours after collection. The tests utilize specific antibodies to identify GAS cell-wall carbohydrate antigen. The throat swab is treated with an acid solution that helps to extract the antigen from the cell wall.10 The RADTs in widespread use today are based on optical immunoassay technology, and results are typically available within minutes of collection. Despite RADT’s potential to diagnosis GAS in a more timely manner than a throat culture, it has been shown in many clinical studies that its sensitivity (typically 70%-90%) is unacceptably low to be relied on alone for diagnosis, so a back-up throat culture is recommended for children with a negative result on RADT; however, the exception to this practice would be in cases where the results of the specific RADT in use have been compared directly with those of the blood agar plate cultures and have confirmed an adequate degree of sensitivity to forgo a back-up throat culture.3 Nevertheless, the sensitivity of RADT can change depending on the severity of illness. There is a well-documented spectrum bias that has shown an increased sensitivity of RADT with the increased severity of illness. In one study the sensitivity of RADT ranged from 59% to 83% based on pretest likelihood of GAS infection; however, even with the highest pretest probability, the negative predictive value was still less than 95%, leading the authors to recommend back-up throat cultures if RADT is negative.74 The specificity of RADT has been found to be quite high (90%-99%), however, meaning that a positive result on RADT is likely to indicate a GAS infection, which can be treated without a back-up throat culture.8 Rapid www.ebmedicine.net • December 2011

Streptococcal Antibody Tests

antigen detection testing is particularly useful in the ED setting where the potential lack of followup makes use of throat culture alone less attractive. Several studies have found that the use of RADT reduces the need to prescribe antibiotics in patients found to have non-GAS causes of pharyngitis, thus decreasing the risk that non-GAS bacteria will develop antibiotic resistance.75,76

The most commonly used tests to detect streptococcal infection are antistreptolysin-O (ASO) and antideoxyribonuclease B (anti-DNase B). These tests are not used regularly but can be useful while working up patients with possible nonsuppurative complications of GAS infection, such as acute rheumatic fever or glomerulonephritis. A rising or elevated antibody titer is useful in diagnosing a past GAS infection, as antibodies can remain elevated for months.3

Throat Culture

Throat culture on a BAP is the standard by which GAS pharyngitis is diagnosed. However, since there is no standard protocol for performing a BAP culture, it has been difficult to compare it directly with RADT. Many factors have been shown to affect the sensitivity of BAP, including the type of medium, duration of incubation, atmosphere of incubation, swab techniques, and the setting (office or laboratory). In a recent study comparing the use of optical immunoassay RADT to office BAP and diagnostic laboratory BAP, the office BAP was found to be significantly more sensitive (81%) than the RADT (70%), but neither test was as good as a laboratory BAP. A combined RADT and back-up office BAP throat culture had higher sensitivity than either test alone (85%) but was still lower than that for the laboratory BAP culture.77 The ED setting typically has the benefit of diagnostic laboratory support and access to the “gold standard” BAP; however, it is vitally important for the clinician to obtain an adequate sample, as described previously. It is also crucial to ensure that accurate call-back information for the patient is available if RADT is negative but the throat culture is positive. Neither RADT nor BAP can distinguish active GAS infection from asymptomatic carriage of the organism in the nasopharynx. In a recent meta-analysis, 12% of children over 5 years of age were found to be GAS carriers.9 Many patients with simultaneously collected negative RADT and positive BAP culture are found to have only small numbers of GAS colonies. Some investigators have suggested that, in such cases, the positive throat culture is due to carriage of streptococcus; however, studies have demonstrated that a large proportion of patients with false-negative results on RADT were actually infected with GAS and were not just carriers.78 Generally speaking, carriers do not need to be identified or treated with antibiotics, since they are at very low risk for rheumatic fever and are not thought to be important in the spread of GAS to their contacts.79 Group A streptococcus carriage can persist for several months after infection and can confuse the diagnosis in new cases of pharyngitis. The current AHA/AAP guideline recommends treating all patients with signs and symptoms of pharyngitis who have a positive result on RADT or BAP culture. Eradication of GAS carriage is sometimes desirable, as discussed in this issue.3 December 2011 • www.ebmedicine.net

Heterophile Antibody Test

Commonly known as a “monospot test,” the heterophile antibody is used to test for infectious mononucleosis. Infection with Epstein-Barr virus induces a heterogeneous group of mostly immunoglobulin M-type (IgM-type) antibodies to interact with an antigen on the surface of infected cells. The monospot test uses epitopes for the cell-surface antigen from nonhuman sources (ie, sheep, horse, guinea pig) that cross-react with the patient’s heterophile antibodies and lead to red blood cell agglutination.64 Antibody levels peak during the first 2 weeks of illness. The heterophile antibody test is quite sensitive (85%) and specific (97%) in adolescents and adults, but it is positive in only 25% to 75% of children under 4 years of age.80 In such cases it is useful to obtain specific serologies for the Epstein-Barr virus (antivasoconstrictor assay, IgM, and immunoglobulin G) to make the diagnosis, the caveat being that most hospital laboratories do not perform these tests on an emergent basis, so results would not be available prior to discharging or admitting the patient.

Complete Blood Count With Differential

A CBC is not useful for diagnosing most causes of pharyngitis. However, infectious mononucleosis has classic findings that, if present, are very helpful in making the diagnosis. Marked lymphocytosis (> 50%) with at least 10% atypical lymphocytes is highly suggestive of infectious mononucleosis. If the total WBC count is significantly elevated, particularly with a left shift, more serious bacterial infections, such as retropharyngeal abscess or Lemierre syndrome, are more likely, particularly if the patient appears ill.

Clinical Scoring Systems

It has been recognized for decades that it is difficult for even experienced practitioners to differentiate GAS pharyngitis from other (usually viral) causes of sore throat on clinical grounds alone. Clinical scoring systems have been developed to address this issue in hopes of avoiding the sequelae of untreated GAS infection while also avoiding unnecessary antibiotic use. In 1977, Breese introduced a pediatric score card based on the finding of fever, headache, cervical adenopathy, erythema, swelling, or exudate 17

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from the pharynx or tonsils; the absence of upper respiratory symptoms (eg, cough, rhinorrhea, or conjunctivitis); epidemiologic factors, including age between 5 and 15 years and time of year (November to May); and laboratory results (an elevated WBC count).81 In 1998, Wald et al simplified the Breese score card to avoid the discomfort of drawing blood by eliminating the WBC count.82 A score of 6 (all criteria met) had a positive predictive value of 75%; however, 23% of patients with a score of only 2 or 3 also had positive throat cultures, leaving a significant number of children with a GAS infection potentially untested and untreated. They concluded that the score card could not replace the use of diagnostic testing for GAS pharyngitis but was potentially useful for targeting patients in whom the RADT was most likely to be positive. The Centor scoring system, first described in 1981 by Centor et al,6 remains one of the standards in the diagnosis of GAS pharyngitis in adolescents (over age 15 years) and adults. It is currently cited in the CDC/AAFP/ACP/ASIM guideline.5 The scoring system is easy to use, having only 4 equally weighted criteria: the presence of tonsillar exudates; swollen, tender anterior cervical lymph nodes; lack of a cough; and a history of fever.6 McIsaac et al developed a modified Centor score that has been validated in children and adults. The criteria measured are the same as Centor’s with points added or subtracted according to the patient’s age.83 Use of the score card to manage patients in several family practice locations in Canada was found to potentially decrease unnecessary antibiotic use by 63.7%.84 It is widely accepted that patients (pediatric and adult) with a score of 0 or 1 require neither testing nor treatment. Otherwise, various advisory committees disagree on how to manage patients with higher scores. The Infectious Diseases Society of America recommends RADT or RADT plus throat culture for patients with a score of 3 or higher before antibiotic therapy is begun. The CDC/ AAFP/ACP/ASIM guideline states that patients with a score of 3 or 4 may be started empirically on antibiotics.5 This practice has been found to be associated with a high rate of unnecessary antibiotic use but has also been defended as an effective way to relieve suffering and expedite return to work.7,85 Limitations in clinical scoring systems include interobserver disagreement regarding physical examination findings86,87 and tendency of physicians to not follow any guidelines. One study found that up to 81% of pediatricians and family practitioners used an inappropriate strategy for dealing with viral pharyngitis.88 Another study showed that 78% of primary care providers in a local healthcare system did not adhere to any guideline.89

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Cost-Effectiveness Of RADT And Throat Culture In Diagnosing GAS Pharyngitis

Cost-effectiveness analysis and decision analysis have been used to evaluate various diagnostic and treatment strategies for GAS pharyngitis. However, it is difficult to compare results between analyses as there is little consistency between them. Most of the recently published analyses do not report costeffectiveness from the same perspective or have the same outcome measurements. One study measured cost-effectiveness in terms of preventing one case of rheumatic heart disease,90 whereas others measured dollars spent per complication (suppurative and nonsuppurative) and cases of severe antibiotic reactions prevented.91,92 Another very recently published cost-effectiveness analysis considered only the insurance payer’s perspective, while others have studied cost-effectiveness from a societal perspective.93 Different rates of sensitivity of RADT and BAP culture are assumed, as are different incidence rates of suppurative and nonsuppurative complications of GAS infections. These inconsistencies lead authors to different conclusions, leaving clinicians without a clearly defined evidence-based strategy. However, the one conclusion that is consistent across all analyses is that although treating all cases of pharyngitis empirically, without any confirmatory testing, is the most effective for avoiding the complications of GAS pharyngitis, this approach results in an unacceptably high rate of unnecessary antibiotic use as well as high morbidity due to severe allergic reactions.

Special Circumstances Clinical scoring systems were developed to determine which patients are most likely to have GAS pharyngitis and are quite useful in everyday practice; several studies have shown that patients with high Centor or modified Centor scores (4 or 5 points) are most likely to have a positive result on RADT. Those with scores of 2 points or less are often not tested. The exception to these recommendations is during an outbreak of rheumatic fever. Although acute rheumatic fever is exceedingly rare in the United States, with an incidence of approximately 1 per 100,000, sporadic outbreaks have been reported since the 1980s in western Pennsylvania, Denver, and Salt Lake City.94 In the unusual circumstance of a local outbreak of rheumatic fever, efforts must be made to identify all possible cases of GAS pharyngitis and may require that clinicians at least obtain throat cultures, even for patients with low clinical scores.

Controversies And Cutting Edge The clinical scoring systems currently in use in the United States, Canada, and other developed www.ebmedicine.net • December 2011

Risk Management Pitfalls To Avoid In The Treatment Of Pediatric Pharyngitis (Continued on page 20) 1. “The patient had swollen, red tonsils with a lot of thick exudates. The RADT was negative, but with the clinical examination I was sure he had GAS, so I prescribed amoxicillin pending the throat culture results. He came back 2 days later with a terrible rash and the throat culture was negative. What’s going on?” The signs and symptoms of GAS pharyngitis are nonspecific, and it can be difficult to differentiate between GAS and other causes of pharyngitis. Infectious mononucleosis, a well-known cause of exudative pharyngitis, is often accompanied by a high fever and swollen cervical lymph nodes. Almost all cases of GAS pharyngitis will resolve within 5 days, even if not treated. Keep this in mind when evaluating a child with pharyngitis of prolonged duration, and broaden the differential diagnosis to include other possibilities besides GAS. An erythematous maculopapular rash often develops in patients with infectious mononucleosis who are treated with ampicillin-like antibiotics, such as amoxicillin. The mechanism of this reaction is not known. Although the rash is not an allergic rash and is not dangerous, it is still unsightly and often upsets caregivers.

Pharyngitis can be very painful and dehydration secondary to decreased oral intake is one of the most common complications. Adequate analgesia can help alleviate pain that would discourage patients from drinking fluids. In addition to acetaminophen and ibuprofen, throat lozenges with mild topical anesthetics can be useful for older children. For younger children, a compounded 1:1 ratio of diphenhydramine and aluminum chloride liquids can help alleviate mouth pain with a mild topical anesthetic effect that is safe for the patient to swallow. Caregivers should be strongly encouraged to offer liquids and soft foods very frequently and to keep a careful eye on the child’s urine output. 4. “I thought the patient had croup but wanted to get a good look at her throat in case she had a foreign body back there. She started crying hard then stopped breathing. She was a tough intubation and ended up in the ICU. I didn’t think kids got epiglottitis anymore.” Children with signs of upper airway obstruction should be approached carefully and allowed to maintain a position of comfort. Agitating the child may lead to crying and possibly complete airway obstruction. Do not examine the ears or mouth or try to reposition the child unless absolutely necessary. In the age of widespread vaccination against HIB, epiglottitis is seen much less commonly in children than in the past but is still a concern in unimmunized or under-immunized children. It is necessary to maintain a high index of suspicion for this rare but potentially deadly infection.

2. “That kid was tough to examine! I think I swabbed her tonsils before she bit down on the culture swab.” Obtaining a throat swab specimen from a pediatric patient can be very challenging, but it is imperative to do so for the RADT and throat cultures to provide the emergency clinician with the most accurate information possible. The tonsils and posterior pharynx need to be swabbed vigorously, and the culturette may not touch the tongue, teeth, or buccal mucosa. Use of a tongue blade is essential. Caregivers should be asked to hold the child firmly against them, facing the practitioner. One arm wraps around the child’s arms and chest while the other hand holds the forehead firmly against the caregiver’s chest. This is the fastest and most efficient way to obtain the swab and avoids having to repeat the procedure in an already anxious patient.

5. “I’ll never miss a case of strep throat because I treat every patient who has a red throat with antibiotics.” More than one cost-effectiveness and decision analysis regarding the diagnosis and treatment of GAS pharyngitis has come to the conclusion that a “treat all” strategy is most effective for avoiding the complications of GAS pharyngitis. However, none of the study authors could recommend this strategy owing to the large number of severe allergic reactions that may occur. In an age of increasing antibiotic resistance, prescribing so many unnecessary antibiotics is also irresponsible. During an epidemic of acute rheumatic fever, this approach may be re-examined, but in everyday practice it is not appropriate.

3. “I saw that child last night and diagnosed him with hand-foot-mouth disease. I told his parents that it was just a virus and that he would be fine in a few days. Has he really not had a wet diaper in 24 hours?”

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Risk Management Pitfalls To Avoid In The Treatment Of Pediatric Pharyngitis (Continued from page 19) 6. “I saw that girl 2 weeks ago and diagnosed strep based on a positive rapid test. She’s back again with a sore throat and fever, and her rapid test was positive again. I thought amoxicillin would be more than enough to treat strep.” Group A streptococcus infection treatment failures may be due to a number of factors, including nonadherence to the prescribed regimen and resistance to the medication prescribed. The patient who presents with symptoms of acute pharyngitis soon after completing treatment for GAS pharyngitis may have been reinfected or may be a carrier of GAS and now has a new viral illness to account for the symptoms. It is recommended that in cases like this, if the RADT is positive and the child has physical findings consistent with GAS infection, another course of an appropriate antibiotic be prescribed. 7. “Teenage girls are impossible! This is her third trip to the ED in 10 days for a sore throat. The rapid test and throat culture are always negative though.” Adolescents present a particular challenge in emergency medicine. In cases such as this, a broader differential diagnosis is clearly required. Obtaining a detailed social history, including sexual history, is imperative, since less frequent causes of pharyngitis such as N gonorrhoeae cannot be cultured on the usual BAP. The acute retroviral syndrome associated with primary HIV infection may present as a mononucleosislike illness. 8. “There was a history of rash with penicillin documented on the chart, so when the rapid strep came back positive, I sent the patient out on erythromycin, but now he’s back and not feeling better. I thought that erythromycin was the first choice for penicillin-allergic patients with strep throat?” Erythromycin is the first choice for penicillinallergic patients with GAS per the Infectious Diseases Society of America and the CDC/

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AAFP/ACP/ASIM guidelines.4,5 However, there have been well-documented cases of erythromycin-resistant GAS. The current AHA/AAP guideline no longer recommends erythromycin because of the greater incidence of gastrointestinal side effects and inconvenient frequency of dosing (4 times a day).3 Azithromycin is the current macrolide of choice, and first-generation cephalosporins can be used for patients without type 1 hypersensitivity reactions to penicillins. 9. “That 16-year-old boy looked sick and had a bad sore throat, but his rapid strep test and monospot were negative, so after I hydrated him, I discharged him with a viral illness. I heard he came back a few days later and is in the ICU with Lemierre syndrome. I remember reading about that once in a journal but thought it was very rare.” F necrophorum, the most common cause of Lemierre syndrome, is recognized as a fairly common cause of pharyngitis in adolescents and young adults, accounting for approximately 10% of cases in recent studies.96,97 There was increased reporting of Lemierre syndrome between 2001 and 2008, according to a recent systematic review.35 It is unclear whether this increase is due to differences in antibiotic prescribing patterns and rising antibiotic resistance. It is important to maintain a high index of suspicion when presented with an ill-appearing patient with sore throat. 10. “I thought I did everything right — diagnosed strep throat, prescribed an appropriate antibiotic — but the patient’s parents complained to Customer Satisfaction that I didn’t care enough about their child’s pain.” No matter the cause of pharyngitis, pain is usually a prominent symptom. Reducing pain not only makes the patient (and their caregivers) more comfortable, it also helps avoid other complications, such as dehydration. Beyond acetaminophen and ibuprofen, it may sometimes be necessary to prescribe stronger analgesics, such as acetaminophen with codeine.

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countries are of limited usefulness in areas with a high incidence of acute rheumatic fever and where rheumatic heart disease is still prevalent. Several investigators working in developing countries with few laboratory resources have tried to modify existing scoring systems or devise new systems with the goal of decreasing the unnecessary use of antibiotics while not missing cases of GAS pharyngitis. Published reports are encouraging but have yet to be validated in different populations.95,98,99 It is desirable to decrease the amount of unnecessary antibiotics prescribed to decrease the development of antibiotic resistance among non-GAS bacteria. Adolescents and young adults present a particular challenge in the diagnosis and treatment of pharyngitis. Although not as susceptible to GAS as younger children, this age group has been found to have more morbidity caused by non-GAS streptococcal and anaerobic bacterial infections. Non–group

A streptococcal disease causes symptoms similar to those seen in GAS infections but is generally not treated because the infections are self-limited and have not been shown to have the serious sequelae of untreated GAS.31 Lemierre syndrome, caused most commonly by the anaerobe F necrophorum was once rare, but a recent review found it to be responsible for up to 10% of cases of pharyngitis.35 This leads us to the continued spirited debate in the literature regarding the empiric use of antibiotics in patients with a Centor score > 3 or a modified Centor score > 4, as recommended by the CDC/AAFP/ACP/ASIM guideline.5 McIsaac et al found that this recommendation led to a high rate of unnecessary antibiotic use (44%).7 However, others have suggested that patients may suffer if not offered treatment for severe sore throat, since routine testing is not available for non–group A streptococcus and anaerobes. These issues highlight the philosophical debate concerning

Cost-Effective Strategies 1. Carefully choose which patients need RADT and/or throat culture. Utilize the Centor score or modified Centor score to screen patients who have a greater likelihood of having GAS pharyngitis, and perform RADT or throat culture accordingly. Practitioners can take advantage of the spectrum bias inherent in RADTs to increase the sensitivity of the test by testing only those patients with higher scores. Patients with obvious symptoms and signs of viral illness such a cough, coryza, diarrhea, or conjunctivitis should not be tested. Risk management caveat: Scoring systems are meant to be used only in areas with an endemic incidence of acute rheumatic fever (currently < 1 per 100,000). Other, more aggressive measures are needed in areas experiencing an epidemic of acute rheumatic fever in order to not miss any cases of GAS pharyngitis.

should be avoided, such as the third-generation cephalosporins, since they lead to increased rates of antibiotic resistance. Risk management caveat: First-generation cephalosporins and azithromycin are the first-choice antibiotics for patients who are allergic to penicillin. 3. Back-up throat cultures are generally not necessary in older adolescents if RADT is negative. The incidence of rheumatic fever is even lower in adolescents (age > 15 years) than it is in children in endemic areas. Therefore, the risk of complications when a case of GAS pharyngitis is missed is much lower than it would be in a school-aged child. This recommendation is endorsed by the Infectious Diseases Society of America as well as the CDC/AAFP/ACP/ASIM guidelines and has been shown to be cost-effective in several decision-making analyses.4,5 Risk management caveat: Adolescents and young adults are more commonly infected with other bacteria causing pharyngitis, including non–group A streptococci, F necrophorum, N gonorrhoeae, and A haemolyticum. Emergency clinicians should keep these organisms in mind, particularly when a patient has symptoms that persist beyond the usual duration or has historical or physical findings suspicious for these other, less common infections.

2. Penicillin V is the preferred first-line treatment for GAS pharyngitis in patients who are not allergic to penicillin. Penicillin V is a narrowspectrum antibiotic that has never had proven GAS resistance. It is inexpensive and conveniently dosed twice a day. The primary drawback of penicillin is its unpalatability in liquid form. For this reason, amoxicillin suspension is more commonly used for pediatric patients. It has only a slightly broader spectrum of activity and is also reasonably priced. Newer antimicrobial agents with broad-spectrum coverage December 2011 • www.ebmedicine.net

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whether it is more important to treat patients who present with a serious sore throat and attempt to relieve their symptoms or to avoid the greater societal risk of antibiotic resistance.85

Disposition Criteria for discharge home from the ED include the ability to tolerate oral fluids, adequately controlled pain, and the presence of an open and patent airway. No matter the cause of pharyngitis, patients and parents must be instructed to strongly encourage the increased intake of fluids and to treat fever and pain as needed with acetaminophen or ibuprofen and other comfort measures appropriate to the patient’s age. Antibiotics, if needed, should be taken exactly as prescribed. Provide the patient and parents with an approximate timeline within which they should observe improvement, and carefully review criteria that should prompt them to return the ED, including any signs of airway obstruction, drooling, signs of dehydration, and the appearance of new symptoms. It is also imperative to have accurate contact information for the patient’s family if the RADT result was negative and a back-up throat culture was ordered.

ing, the patient was given ibuprofen and became afebrile. He was discharged home with instructions for his parents to follow up with his pediatrician in the next 2 to 3 days to recheck his throat and abdomen and to return to the ED if he has any difficulty breathing or swallowing.

References Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report. To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference. 1. 2.

Summary Pharyngitis is one of the most common complaints seen in the ED. The principal goal of the emergency clinician is to differentiate between life-threatening and non-life-threatening causes of pharyngitis by maintaining a high index of suspicion and performing a thorough history and physical examination. If deemed necessary, a thoughtful selection of tests based on these findings will provide additional evidence that leads to the correct diagnosis and guides treatment. The judicious use of antibiotics to treat GAS pharyngitis will prevent potentially serious sequelae and prevent the development of antibiotic resistance.

3.*

4.*

5.

Case Conclusion After 90 minutes, you returned to the room to discuss the results of the laboratory studies. CBC with differential revealed a normal WBC count of 10,000, with 54% lymphocytes and 12% atypical lymphocytes. The heterophile antibody test was positive. You explained to the mother that the patient appeared to have infectious mononucleosis caused by the Epstein-Barr virus. The mother asked what kind of medicine you planned to prescribe to fix him. You told her that the illness would have to run its course but that with adequate hydration and pain management her son should be feeling better within a week. Since he continued to be in no respiratory distress, you decided to withhold steroids. While the laboratory results were pendPediatric Emergency Medicine Practice © 2011 22

6.*

7.*

8.* 9.

10.

Linder JA, Bates DW, Lee GM, et al. Antibiotic treatment of children with sore throat. JAMA. 2005;294(18):2315-2322. (Retrospective; 4158 patients) Pfoh E, Wessels MR, Goldmann D, Lee GM, et al. Burden and economic cost of group A streptococcal pharyngitis. Pediatrics. 2008;121(2):229-234. (Descriptive analysis; 135 patients) 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(11):1541-1551. (Guideline statement) Bisno AL, Gerber MA, Gwaltney Jr. JM, et al. Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of group A streptococcal pharyngitis. Clin Infect Dis. 2002;35(2):113-125. (Guideline statement) Snow V, Mottur-Pilson C, Cooper RJ, et al; American Academy of Family Physicians; American College of Physician - American Society of Internal Medicine; Centers for Disease Control. Principles of appropriate antibiotic use for acute pharyngitis in adults. Ann Intern Med. 2001;134(6):506-508. (Guideline statement) Centor RM, Witherspoon JM, Dalton HP, et al. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-246. (Prospective, descriptive; 234 patients) McIsaac WJ, Kellner JD, Aufricht P, et al. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA. 2004;291(13):1587-1595. (Prospective; 787 patients) Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin Microbiol Rev. 2004;17(3):571-580. (Review) Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a metaanalysis. Pediatrics. 2010;126(3):e557-e564. (Meta-analysis; 29 studies) Wessels MR. Clinical practice. Streptococcal pharyngitis. N

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Engl J Med. 2011;364(7):648-655. (Review) 11. Bisno AL. Acute pharyngitis. N Engl J Med. 2001;344(3):205211. (Review) 12. Bulloch B, Kabani A, Tenenbein M. Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial. Ann Emerg Med. 2003;41(5):601-608. (Randomized, double-blind, placebo-controlled; 184 patients) 13. Korb K, Scherer M, Chenot JF. Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: a systematic review. Ann Fam Med. 2010;8(1):58-63. (Systematic review; 806 patients) 14. Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010;362(21):1993-2000. (Review) 15. Rafei K, Lichenstein R. Airway infectious disease emergencies. Pediatr Clin North Am. 2006;53(2):215-242. (Review) 16. Centers for Disease Control and Prevention (CDC). Progress toward elimination of Haemophilus influenzae type b invasive disease among infants and children — United States, 1998–2000. MMWR Morb Mortal Wkly Rep. 2002;51(11):234237. (Report of data, 1998–2000) 17. McVernon J, Slack MP, Ramsay ME. Changes in the epidemiology of epiglottitis following introduction of Haemophilus influenzae type b (Hib) conjugate vaccines in England: a comparison of two data sources. Epidemiol Infect. 2006;134(3):570-572. (Retrospective; 524 patients) 18. Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol. 2008;122(8):818-823. (Retrospective; 35 patients) 19. Shah RK, Roberson DW, Jones DT. Epiglottitis in the Haemophilus influenzae type B vaccine era: changing trends. Laryngoscope. 2004;114(3):557-560. (Retrospective; 19 patients) 20. Tanner K, Fitzsimmons G, Carrol ED, et al. Haemophilus influenzae type b epiglottitis as a cause of acute upper airways obstruction in children. BMJ. 2002;325(7372):1099-1100. (Review) 21. Glynn F, Fenton JE. Diagnosis and management of supraglottitis (epiglottitis). Curr Infect Dis Rep. 2008;10(3):200-204. (Review) 22. Ng HL, Sin LM, Li MF, et al. Acute epiglottitis in adults: a retrospective review of 106 patients in Hong Kong. Emerg Med J. 2008;25(5):253-255. (Retrospective; 106 patients) 23. Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2007;21(2):449-469, vii. (Review) 24. Ungkanont K, Yellon RF, Weissman JL, et al. Head and neck space infections in infants and children. Otolaryngol Head Neck Surg. 1995;112(3):375-382. (Retrospective; 117 patients) 25. Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics. 2003;111(6 Pt 1):1394-1398. (Retrospective; 64 patients) 26. Poluri A, Singh B, Sperling N, et al. Retropharyngeal abscess secondary to penetrating foreign bodies. J Craniomaxillofac Surg. 2000;28(4):243-246. (Retrospective; 37 patients) 27. Singh B, Kantu M, Har-El G, et al. Complications associated with 327 foreign bodies of the pharynx, larynx, and esophagus. Ann Otol Rhinol Laryngol. 1997;106(4):301-304. (Retrospective; 327 patients) 28. Chan TV. The patient with sore throat. Med Clin North Am. 2010;94(5):923-943. (Review) 29. Page NC, Bauer EM, Lieu JE. Clinical features and treatment of retropharyngeal abscess in children. Otolaryngol Head Neck Surg. 2008;138(3):300-306. (Retrospective; 162 patients) 30. Schraff S, McGinn JD, Derkay CS. Peritonsillar abscess in children: a 10-year review of diagnosis and management. Int J Pediatr Otorhinolaryngol. 2001;57(3):213-218. (Retrospective; 83 patients) 31. Friedman NR, Mitchell RB, Pereira KD, et al. Peritonsillar abscess in early childhood. Presentation and management.

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Arch Otolaryngol Head Neck Surg. 1997;123(6):630-632. (Retrospective; 7 patients) 32. Goldstein NA. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL, eds. Textbook of Pediatric Infectious Diseases. 6th ed. Philadelphia, PA: Saunders; 2009:177. (Textbook chapter) 33. Galioto NJ. Peritonsillar abscess. Am Fam Physician. 2008;77(2):199-202. (Review) 34. Williams A, Nagy M, Wingate J, et al. Lemierre syndrome: a complication of acute pharyngitis. Int J Pediatr Otorhinolaryngol. 1998;45(1):51-57. (Review) 35. Karkos PD, Asrani S, Karkos CD, et al. Lemmierres syndrome: A systematic review. Laryngoscope. 2009;119(8):15521559. (Systematic review; 114 patients) 36. Goldenberg NA, Knapp-Clevenger R, Hays T, et al. Lemmierres and Lemmierres-like syndromes in children: survival and thromboembolic outcomes. Pediatrics. 2005;116(4):e543e548. (Retrospective; 9 patients) 37. Vitek CR, Wharton M. Diphtheria in the former Soviet Union: reemergence of a pandemic disease. Emerg Infect Dis. 1998;4(4):539-550. (Review) 38.* Spinks A, Glasziou PP, Del Mar C. Antibiotics for sore throat (review). Cochrane Database Syst Rev. 2010;9:1-42. (Systematic review; 12,835 patients) 39.* van Driel ML, De Sutter AI, Keber N, et al. Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database Syst Rev. 2010;(10):CD004406. (Systematic review; 5352 patients) 40. Altamimi S, Khalil A, Khalaiwi KA, et al. Short versus standard duration antibiotic therapy for acute streptococcal pharyngitis in children. Cochrane Database Syst Rev. 2009;(1):CD004872. (Systematic review; 13,102 patients) 41. Gerber MA, Tanz RR, Kabat W, et al. Potential mechanisms for failure to eradicate group A streptococci from the pharynx. Pediatrics. 1999;104(4 Pt 1):911-917. (Prospective, randomized, clinical; 462 patients) 42. Lennon DR, Farrell E, Martin DR, et al. Once-daily amoxicillin versus twice-daily penicillin V in group A beta-haemolytic streptococcal pharyngitis. Arch Dis Child. 2008;93(6):474478. (Randomized, noninferiority; 353 patients) 43. Clegg HW, Ryan AG, Dallas SD, et al. Treatment of streptococcal pharyngitis with once-daily compared with twicedaily amoxicillin: a noninferiority trial. Pediatr Infect Dis J. 2006;25(9):761-767. (Randomized, controlled, single-blind, noninferiority; 652 patients) 44. Pichichero ME. Defining and dealing with carriers of group A streptococci. Contemp Pediatrics. 2003;20(1):46-56. (Review) 45. Baltimore RS. Re-evaluation of antibiotic treatment of streptococcal pharyngitis. Curr Opin Pediatr. 2010;22(1):77-82. (Review) 46. 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):1-4. (Retrospective cohort; 265 patients) 47. Tiemstra J, Miranda RL. Role of non–group a streptococci in acute pharyngitis. J Am Board Fam Med. 2009;22(6):663-669. (Retrospective; 915 patients) 48. Karpathios T, Drakonaki S, Zervoudaki A, et al. Arcanobacterium haemolyticum in children with presumed streptococcal pharyngotonsillitis or scarlet fever. J Pediatr. 1992;121(5 Pt 1):735-737. (Retrospective; 129 patients) 49. Mackenzie A, Fuite LA, Chan FT, et al. Incidence and pathogenicity of Arcanobacterium haemolyticum during a 2-year study in Ottawa. Clin Infect Dis. 1995;21(1):177-181. (Prospective; 11,620 patients) 50. Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2007;21(2):449-469, vii. (Review) 51. Wiesner PJ, Tronca E, Bonin P, et al. Clinical spectrum of pharyngeal gonococcal infection. N Engl J Med. 1973;288(4):181-

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185. (Prospective; 150 patients) 52. Abbott SL. Gonococcal tonsillitis-pharyngitis in a 5-year-old girl. Pediatrics. 1973;52(2):287-289. (Case report) 53. Powell D. Mycoplasma pneumoniae. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson’s Textbook of Pediatrics. 17th ed. Philadelphia, PA: Saunders; 2004:990-992. (Textbook chapter) 54. Schutze GE JR. Tularemia (Francisella tularensis). In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson’s Textbook of Pediatrics. 17th ed. Philadephia, PA: Saunders; 2004:937-939. (Textbook chapter) 55. McIntosh K. Adenoviruses. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson’s Textbook of Pediatrics. 17th ed. Philadelphia, PA: Saunders; 2004:1079-1080. (Textbook chapter) 56. Dominguez O, Rojo P, de Las Heras S, et al. Clinical presentation and characteristics of pharyngeal adenovirus infections. Pediatr Infect Dis J. 2005;24(8):733-734. (Retrospective; 209) 57. Hall CB. Respiratory syncytial virus and parainfluenza virus. N Engl J Med. 2001;344(25):1917-1928. (Review) 58. Modlin JF, Rotbart HA. Group B coxsackie disease in children. Curr Top Microbiol Immunol. 1997;223:53-80. (Review) 59. Annunziato PW, Gershon A. Herpes simplex virus infections. Pediatr Rev. 1996;17(12):415-423. (Review) 60. McMillan JA, Weiner LB, Higgins AM, et al. Pharyngitis associated with herpes simplex virus in college students. Pediatr Infect Dis J. 1993;12(4):280-284. (Prospective; 613 patients) 61. Amir J, Harel L, Smetana Z, et al. Treatment of herpes simplex gingivostomatitis with acyclovir in children: a randomised double blind placebo controlled study. BMJ. 1997;314(7097):1800-1803. (Randomized double-blind placebo-controlled; 72 patients) 62. Gaines H, von Sydow M, Pehrson PO, Lundbegh P. Clinical picture of primary HIV infection presenting as a glandularfever–like illness. BMJ. 1988;297(6660):1363-1368. (Prospective, descriptive; 20 patients) 63. Cooper DA, Gold J, Maclean P, et al. Acute AIDS retrovirus infection. Definition of a clinical illness associated with seroconversion. Lancet. 1985;1(8428):537-540. (Retrospective; 12 patients) 64. Hurt C, Tammaro D. Diagnostic evaluation of mononucleosis-like illnesses. Am J Med. 2007;120(10):911.e1-911.e8. (Review) 65. Ebell MH. Epstein-Barr virus infectious mononucleosis. Am Fam Physician. 2004;70(7):1279-1287. (Review) 66. Luzuriaga K, Sullivan JL. Infectious mononucleosis. N Engl J Med. 2010;362(21):1993-2000. (Review) 67. Candy B, Hotopf M. Steroids for symptom control in infectious mononucleosis. Cochrane Database Syst Rev. 2006;3:CD004402. (Systematic review; 7 trials) 68. Newburger JW, Takahashi M, Gerber MA, et al. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Pediatrics. 2004;114(6):1708-1733. (Guideline statement) 69. Su CW, Gaskie S, Jamieson B, et al. Clinical inquiries. What is the best treatment for oral thrush in healthy infants? J Fam Pract. 2008;57(7):484-485. (Review) 70. Pienaar ED, Young T, Holmes H. Interventions for the prevention and management of oropharyngeal candidiasis associated with HIV infection in adults and children. Cochrane Database Syst Rev. 2010;(11):CD003940. (Systematic review; 3445 patients) 71. Grosso J, Myer CM, Wood BP. Radiological cases of the month. Retropharyngeal abscess. Am J Dis Child. 1990;144(12):1349-1350. (Case report) 72.* Spinks A, Glasziou PP, Del Mar C. Antibiotics for sore throat (review). Cochrane Database Syst Rev. 2010;9:1-42. (Systematic

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review; 12,835 patients) 73.* Shulman ST, Tanz RR. Group A streptococcal pharyngitis and immune-mediated complications: from diagnosis to management. Expert Rev Anti Infect Ther. 2010;8(2):137-150. (Review) 74. Hall MC, Kieke B, Gonzales R, et al. Spectrum bias of a rapid antigen detection test for group A beta-hemolytic streptococcal pharyngitis in a pediatric population. Pediatrics. 2004;114(1):182-186. (Retrospective; 561 patients) 75. Ayanruoh S, Waseem M, Quee F, et al. Impact of rapid streptococcal test on antibiotic use in a pediatric emergency department. Pediatr Emerg Care. 2009;25(11):748-750. (Retrospective; 8280 patients) 76. Al-Najjar FY, Uduman SA. Clinical utility of a new rapid test for the detection of group A streptococcus and discriminate use of antibiotics for bacterial pharyngitis in an outpatient setting. Int J Infect Dis. 2008;12(3):308-311. (Prospective; 505 patients) 77. 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(2):437-444. (Prospective; 1848) 78. Gerber MA, Randolph MF, Chanatry J, et al Antigen detection test for streptococcal pharyngitis: evaluation of sensitivity with respect to true infections. J Pediatr. 1986;108(5 Pt 1):654-658. (Prospective; 313 patients) 79. Kaplan EL. The group A streptococcal upper respiratory tract carrier state: an enigma. J Pediatr. 1980;97(3):337-345. (Review) 80. Peter J, Ray CG. Infectious mononucleosis. Pediatr Rev. 1998;19(8):276-279. (Review) 81.* Breese BB. A simple scorecard for the tentative diagnosis of streptococcal pharyngitis. Am J Dis Child. 1977;131(5):514517. (Prospective, descriptive; 67 patients) 82. Wald ER, Green MD, Schwartz B, et al. A streptococcal score card revisited. Pediatr Emerg Care. 1998;14(2):109-111. (Prospective, descriptive; 365 patients) 83.* McIsaac WJ, White D, Tannenbaum D, et al. A clinical score to reduce unnecessary antibiotic use in patients with sore throat. CMAJ. 1998;158(1):75-83. (Prospective, descriptive; 521 patients) 84. McIsaac WJ, Goel V, To T, et al. The validity of a sore throat score in family practice. CMAJ. 2000;163(7):811-815. (Prospective cohort; 619 patients) 85. Centor RM, Allison JJ, Cohen SJ. Pharyngitis management: defining the controversy. J Gen Intern Med. 2007;22(1):127130. (Opinion) 86. Jensen DM, Brousseau DC, Tumpach EA, et al. Intervention to improve interobserver agreement in the assessment of children with pharyngitis. Pediatr Emerg Care. 2005;21(4):238241. (Prospective, non-blinded, sequential intervention trial; 200 patients) 87. Schwartz K, Monsur J, Northrup J, et al. Pharyngitis clinical prediction rules: effect of interobserver agreement: a MetroNet study. J Clin Epidemiol. 2004;57(2):142-146. (Crosssectional; 200 patients) 88. Park SY, Gerber MA, Tanz RR, et al. Clinicians’ management of children and adolescents with acute pharyngitis. Pediatrics. 2006;117(6):1871-1878. (Survey; 948 physician responses) 89. Linder JA, Chan JC, Bates DW. Evaluation and treatment of pharyngitis in primary care practice: the difference between guidelines is largely academic. Arch Intern Med. 2006;166(13):1374-1379. (Retrospective; 2097 patients) 90. Ehrlich JE, Demopoulos BP, Daniel KR Jr, Ricarte MC, Glied S, et al. Cost-effectiveness of treatment options for prevention of rheumatic heart disease from Group A streptococcal pharyngitis in a pediatric population. Prev Med. 2002;35(3):250-257. (Cost-effectiveness study) 91. Lieu TA, Fleisher GR, Schwartz JS. Cost-effectiveness of

www.ebmedicine.net • December 2011

1. Which of the following recommendations is common to all pharyngitis treatment guidelines examined in this article? a. RADT or treatment should not be carried out for patients with symptoms suggestive of viral illness. b. RADT or throat culture should be performed for patients presenting with symptoms suggestive of GAS infection. c. Utilize a scoring system to determine when a patient needs RADT or presumptive treatment for GAS infection. d. None of the above

rapid latex agglutination testing and tthroat culture for streptococcal pharyngitis. Pediatrics. 1990;85(3):246-256. (Cost-effectiveness study) 92. Webb KH. Does culture confirmation of high-sensitivity rapid streptococcal tests make sense? A medical decision analysis. Pediatrics. 1998;101(2):E2. (Decision analysis) 93. Giraldez-Garcia C, Rubio B, Gallegos-Braun JF, et al. Diagnosis and management of acute pharyngitis in a paediatric population: a cost-effectiveness analysis. Eur J Pediatr. 2011. (Decision analysis) 94. Martin JM, Barbadora KA. Continued high caseload of rheumatic fever in western Pennsylvania: Possible rheumatogenic emm types of streptococcus pyogenes. J Pediatr. 2006;149(1):58-63. (Retrospective chart review and prospective cohort; 121 patients and 231 patients) 95. Smeesters PR, Campos D Jr, Van Melderen L, de Aguiar E, Vanderpas J, Vergison A. Pharyngitis in low-resources settings: a pragmatic clinical approach to reduce unnecessary antibiotic use. Pediatrics. 2006;118(6):e1607-e1611. (Prospective cohort; 220 patients) 96. Amess JA, O’Neill W, Giollariabhaigh CN, Dytrych JK. A sixmonth audit of the isolation of Fusobacterium necrophorum from patients with sore throat in a district general hospital. Br J Biomed Sci. 2007;64(2):63-65. (Prospective; 1157 patients) 97. Batty A, Wren MW. Prevalence of Fusobacterium necrophorum and other upper respiratory tract pathogens isolated from throat swabs. Br J Biomed Sci. 2005;62(2):66-70. (Prospective; 248 patients) 90. Pichichero ME. Defining and dealing with carriers of group A streptococci. Contemp Pediatrics. 2003;20(1):46-56. (Review) 98. Joachim L, Campos D,Jr, Smeesters PR. Pragmatic scoring system for pharyngitis in low-resource settings. Pediatrics. 2010;126(3):e608-e614. (Prospective, descriptive; 576 patients) 99. Fischer Walker CL, Rimoin AW, Hamza HS, Steinhoff MC. Comparison of clinical prediction rules for management of pharyngitis in settings with limited resources. J Pediatr. 2006;149(1):64-71. (Comparative analysis; 410 patients) 100. Fischer J, Pschorn U, Vix JM, et al. Efficacy and tolerability of ambroxol hydrochloride lozenges in sore throat. Randomised, double-blind, placebo-controlled trials regarding the local anaesthetic properties. Arzneimittelforschung. 2002;52(4):256-263. (Prospective, placebo-controlled, randomized, double-blind; 331 patients)

2. Which of the following statements is NOT true? a. Most cases of pharyngitis are spread via respiratory droplets and aerosol dispersion. b. School-aged children between the ages of 5 and 15 are the most often affected by pharyngitis. c. The vast majority of pharyngitis cases are caused by bacteria. d. GAS is the most common organism causing bacterial pharyngitis. 3. Classic symptoms of epiglottitis include: a. Sore throat b. Fever c. Muffled voice d. All of the above 4. Pharyngoconjunctival fever is a clinically distinct syndrome caused by a specific serotype of adenovirus that is characterized by: a. High fever (> 39o C [102.2o F]) b. Pharyngitis with or without tonsillar exudates c. Nonpurulent conjunctivitis, rhinitis, and preauricular and cervical adenopathy d. All of the above

CME Questions Take This Test Online!

5. Plain radiographs of the neck can be helpful if which of the following are suspected? a. Retropharyngeal abscess b. Foreign-body aspiration c. Both A & B d. None of the above

Current subscribers receive CME credit absolutely free by completing the following test. Monthly online testing is now available for current and archived issues. Visit http://www.ebmedicine.net/CME Take This Test Online! today to receive your free CME credits. Each issue includes 4 AMA PRA Category 1 CreditsTM, 4 ACEP Category I credits, 4 AAP Prescribed credits, and 4 AOA category 2A or 2B credits.

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6. GAS is the only bacterial cause of pharyngitis that is not regularly treated with antibiotics. a. True b. False

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7. Which of the following is NOT true regarding the use of penicillin in the treatment of children with GAS? a. The taste of penicillin can make it difficult to administer to children. b. Amoxicillin has been shown to be less palatable that penicillin and is not an acceptable substitute. c. Amoxicillin given once per day has been shown to be as effective as penicillin V given twice per day. d. None of the above 8. There are no specific recommendations for empirically treating children for GAS without first performing RADT or obtaining a BAP throat culture. a. True b. False 9. Adolescents and young adults present a particular challenge in the diagnosis and treatment of pharyngitis because: a. Young adults are more susceptible to GAS than younger children. b. Young adults have a higher morbidity caused by non-GAS streptococcal and anaerobic bacterial infections c. Both A & B d. None of the above 10. Criteria for discharge home after treatment of pharyngitis includes: a. Ability to tolerate fluids b. Adequately controlled pain c. Open and patent airway d. All of the above

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Recognizing signs of traumatic brain injury and improving outcomes Establishing a stable airway Resolving fluid administration debates and providing appropriate resuscitation Employing diagnostic modalities that impact patient management Recognizing and reversing shock Choosing the appropriate endotracheal tube Identifying appropriate facilities and equipment Overcoming the challenges of treating children vs. adults Using and interpreting the FAST examination Evaluating the use of diagnostic peritoneal lavage Reviewing guidelines for the care of pediatric head injuries Diagnosing and treating spinal cord injury and thoracic trauma Providing specialized pediatric orthopedic care To receive your free copy of Initial Evaluation And Resuscitation Of The Injured Child, including 4 CME credits, visit www.ebmedicine.net/renew and use Promotion Code RBPAP.

Class Of Evidence Definitions Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions. Class I • Always acceptable, safe • Definitely useful • Proven in both efficacy and effectiveness

Level of Evidence: • 1 or more large prospective studies are present (with rare exceptions) • High-quality meta-analyses • Study results consistently positive and compelling

Class II • Safe, acceptable • Probably useful

Level of Evidence: • Generally higher levels of evidence • Non-randomized or retrospective studies: historic, cohort, or case control studies • Less robust RCTs • Results consistently positive

Class III • May be acceptable • Possibly useful • Considered optional or alternative treatments

Level of Evidence: • Generally lower or intermediate levels of evidence • Case series, animal studies, consensus panels • Occasionally positive results

Indeterminate • Continuing area of research • No recommendations until further research

Level of Evidence: • Evidence not available • Higher studies in progress • Results inconsistent, contradictory • Results not compelling Significantly modified from: The Emergency Cardiovascular Care Committees of the American Heart Association and represen-

tatives from the resuscitation councils of ILCOR: How to Develop Evidence-Based Guidelines for Emergency Cardiac Care: Quality of Evidence and Classes of Recommendations; also: Anonymous. Guidelines for cardiopulmonary resuscitation and emergency cardiac care. Emergency Cardiac Care Committee and Subcommittees, American Heart Association. Part IX. Ensuring effectiveness of communitywide emergency cardiac care. JAMA. 1992;268(16):2289-2295.

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Copyright © 2010 EB Practice, LLC d.b.a. EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Practice, LLC d.b.a. EB Medicine.

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Y (F our or s a for lim o ite nly d $4 tim 9 e) !

Patient Satisfaction In The Pediatric Emergency Department

With the latest research report from EB Medicine, Patient Satisfaction In The Pediatric Emergency Department, you’ll be able to effectively monitor your patients’ satisfaction to ensure that their needs are not overlooked, that negative perceptions of care are not created, and that initiatives are created to implement to ensure effective, safe, efficient, timely, and equitable care. This report provides the reader with evidence-based concepts that can be easily integrated into the daily clinical practice of emergency medicine. n Table of Contents • Introduction • Patient, Client, or Customer? • How Do Physicians Respond To Customer Service Feedback? • Reasons To Enhance Overall Patient Satisfaction l Patient Satisfaction And Effective Clinical Care l Patient Satisfaction And Litigation Risk l Patient Satisfaction And Staff Satisfaction l Patient Satisfaction And Fiscal Success • Fostering Patient-Centered Care In Medical Trainees • Patient Satisfaction In Pediatric Emergency Medicine • Sources Of Input l Unsolicited Patient Feedback l Solicited Patient Feedback n Telephone Surveys n Mailed Surveys n Other Tools n Customer Service Liaisons n Patient Rounds By ED Leadership Team n In-house Suggestion Card n Customer Feedback Page n Staff Reminders n Discharge Callback Process • Factors That Correlate With Patient Satisfaction l Length Of Stay (LOS) l Effective Communication l Demographic Variables n Daily And Seasonal Variations n Acuity n Pain Management n Physician Gender n Physicians In Training

n Authors Naghma S. Khan, MD Division Director, Pediatric Emergency Medicine, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA Melissa S. Madden, MD Guest Services Coordinator, Emergency Services, Children’s Healthcare of Atlanta, Atlanta, GA John S. Misdary, MD Fellow, Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, GA n Peer Reviewers Alson Inaba, MD, FAAP, PALS-NF Pediatric Emergency Medicine Attending Physician, Kapiolani Medical Center for Women & Children; Associate Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine, Honolulu, HI; Pediatric Advanced Life Support National Faculty Representative, American Heart Association, Hawaii and Pacific Island Region Mike Witt, MD, MPH, FACEP, FAAP Medical Director, Pediatric Emergency Medicine, Elliot Hospital, Manchester, NH

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Pediatric Emergency Medicine Practice © 2011

Coming In Future Pediatric Emergency Medicine Practice Issues •

Intussusception

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Constipation

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Managing The Pediatric Airway

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Sinusitis

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Appendicitis

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Croup

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The Limping Child

Physician CME Information Date of Original Release: December 1, 2011. Date of most recent review: November 10, 2011. Termination date: December 1, 2014. Accreditation: EB Medicine is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only credit commensurate with the extent of their participation in the activity. ACEP Accreditation: Pediatric Emergency Medicine Practice is also approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription. AAP Accreditation: This continuing medical education activity has been reviewed by the American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per year. These credits can be applied toward the AAP CME/CPD Award available to Fellows and Candidate Fellows of the American Academy of Pediatrics. AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American Osteopathic Association Category 2A or 2B credit hours per year. Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for emergency physicians. Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents. Goals: Upon reading Pediatric Emergency Medicine Practice, you should be able to: (1) demonstrate medical decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and treat the most critical ED presentations; and (3) describe the most common medicolegal pitfalls for each topic covered. Discussion of Investigational Information: As part of the newsletter, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product. Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME-sponsored educational activities. All faculty participating in the planning or implementation of a sponsored activity are expected to disclose to the audience any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. Presenters must also make a meaningful disclosure to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were asked to complete a full disclosure statement. The information received is as follows: Dr. Weglowski, Dr. Caglar, Dr. Sharieff, Dr. Whiteman, and their related parties report no significant financial interest or other relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.

Pediatric Emergency Medicine Practice Subscribers

Your subscription includes FREE CME: up to 48 AMA PRA Category 1 CreditsTM, 48 ACEP Category 1 credits, 48 AAP Prescribed credits, and 48 AOA Category 2A or 2B credits per year from current issues, plus an additional 144 credits online. To receive your free credits, simply mail or fax the 6-month print answer form mailed with your June and December issues to EB Medicine or log in to your free online account at www.ebmedicine.net/CME.

Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website. Adobe Reader is required to download archived articles. Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit http://www.ebmedicine.net/policies. Method of Participation: Print Subscription Semester Program: Paid subscribers who read all CME articles during each Pediatric Emergency Medicine Practice six-month testing period, complete the post-test and the CME Evaluation Form distributed with the June and December issues, and return it according to the published instructions are eligible for up to 4 hours of CME credit for each issue. You must complete both the post-test and CME Evaluation Form to receive credit. Results will be kept confidential. Online Single-Issue Program: Current, paid subscribers who read this Pediatric Emergency Medicine Practice CME article and complete the online post-test and CME Evaluation Form at ebmedicine.net/CME are eligible for up to 4 hours of Category 1 credit toward the AMA Physician’s Recognition Award (PRA). You must complete both the post-test and CME Evaluation Form to receive credit. Results will be kept confidential.

Please contact us at 1-800-249-5770 or [email protected] if you have any questions or comments.

CEO: Robert Williford; President & Publisher: Stephanie Williford; Director of Member Services: Liz Alvarez Managing Editor & CME Director: Jennifer Pai; Managing Editor: Dorothy Whisenhunt; Director of Marketing: Robin Williford

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Subscription Information: 1 year (12 issues) including evidence-based print issues; 48 AMA PRA Category 1 CreditsTM, 48 ACEP Category 1 Credits, 48 AAP Prescribed credits, and 48 AOA Category 2A or 2B credit; and full online access to searchable archives and additional free CME: $299 (Call 1-800-249-5770 or go to www.ebmedicine.net/subscribe to order) Single issues with CME may be purchased at www.ebmedicine.net/PEMPissues

Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB Medicine. 5550 Triangle Parkway, Suite 150, Norcross, GA 30092. Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained herein are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Medicine. Copyright © 2011 EB Medicine All rights reserved. No part of this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only, and may not be copied in whole or in part or redistributed in any way without the publisher’s prior written permission – including reproduction for educational purposes or for internal distribution within a hospital, library, group practice, or other entity.

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www.ebmedicine.net • December 2011