Case Study

Pharyngitis
Content produced by the Alliance for the Prudent Use of Antibiotics (APUA) through an unrestricted educational grant from Alere Inc.
Copyright © 2014 the Alliance for the Prudent Use of Antibiotics (APUA)

Reported by:

Shira Doron, MD, Assistant Professor, Division of Infectious Diseases, Associate Hospital
Epidemiologist, Antimicrobial Management ,Tufts Medical Center , Boston, MA

Kirthana Beaulac, PharmD, Clinical Pharmacy Specialist- Infectious Diseases and Antimicrobial
Stewardship, Tufts Medical Center, Boston, MA

LL is a 12 year old female presenting to her pediatrician, complaining of sore throat and cough. She
has had some hoarseness in her voice over the past few days and subjective sweats but no documented
fever. She has a history of seasonal allergies in the fall, and takes loratidine only during that season.
Upon review of systems, she complains of isolated throat pain, without any rhinorrhea, sinus pressure,
or headache. Her mother has been taking her temperature at home, and they have fluctuated from
97.8oF- 99.2oF

Vitals

Tcurr = 99.0oF, 37.2oC

Physical exam
• General: relatively comfortable healthy child

• HEENT: pupils equally round and reactive to light and accommodation, no sinus tenderness,
enlarged tonsils

• Neck: supple, mild lymphadenopathy

• Resp: normal breath sounds

• Card: regular rate and rhythm, no murmurs, rubs, or gallops

• Abd: non-tender, non-distended

• Ext: no edema

• Skin: no rashes

• Neuro: normal for age

Copyright © 2014 the Alliance for the Prudent Use of Antibiotics (APUA) 120001636 11/14
Labs
Na: 1344 Creatinine: 0.6
K: 4.6 WBC: 8.6
Cl: 101 Hgb: 13.6
Bicarb: 25 Hct: 40.8
BUN: 18 Platelets: 333

Micro
• Rapid Strep Antigen = Negative

• Throat Culture = Pending

LL was given a prescription for ibuprofen, to help with the inflammation and subjective fevers. She
was not given a prescription for antibiotics, but the pediatrician advised the patient and her mother
that he would call in a prescription for amoxicillin if the culture returned positive. She was
encouraged to drink plenty of fluids and rest. The culture returned negative after 48 hours and she
symptomatically improved after 2 days.

Acute Group A Streptococcal Pharyngitis (GAS) is a common condition affecting mostly children and
teenagers during the winter and early spring. While GAS is the most common bacterial cause of
pharyngitis, acute pharyngitis is most commonly caused by viruses.1 GAS is the causative organism
in 20-30% of cases of pharyngitis, but can increase to 35-50% depending on the population and
season.2,3 Notably, the symptoms of viral and bacterial pharyngitis can be challenging to differentiate.
However, LL’s cough and hoarseness without any abdominal symptoms, fever, headache, or rash
suggest that a viral illness was more likely than GAS.1

Given the age of the patient, time of year, and clinical symptoms, testing for GAS pharyngitis was
warranted. The gold standard for diagnosis of GAS pharyngitis is the culture of a throat swab on a
sheep-blood agar plate.1 The results can be variable based on the technique by which the swab was
obtained. The swab should be obtained from the surface of either of the tonsils and the posterior
pharyngeal wall without touching other parts of the oral pharynx and mouth.4,5 Also, the culture must
be incubated for at least 18-24 hours prior to interpreting results, and should not be read as negative
until incubated for 48 hours.6

Another diagnostic alternative is the Rapid Strep Antigen Detection Test (RADT). This test can be
performed easily in the outpatient setting and has a rapid turnaround time.1 In comparison to throat
cultures, RADTs are over 95% specific but only 70-90% sensitive.7,8 Therefore, the Infectious
Diseases Society of America recommends liberal testing and that a negative RADT result warrants
further confirmatory testing with a throat culture. However, in a patient without overt signs of
bacterial pharyngitis and a negative RADT, it is appropriate to treat as if the patient has viral
pharyngitis while awaiting results of the culture, as the pre-test probability of GAS is low.1 The
European Society of Clinical Microbiology and Infectious Diseases (ESCMID) recommends risk
stratification and rapid testing of patients with high probability of GAS. In these clinical situations,
the pre-test probability of a positive result is higher, and therefore, negative RADT results do not
warrant further confirmatory culturing.9

It is estimated that 70% of patients complaining of sore throat receive antibiotics, while the vast
majority do not have bacterial infections.10 Therefore, differentiating between viral and bacterial

Copyright © 2014 the Alliance for the Prudent Use of Antibiotics (APUA) 120001636 11/14
pharyngitis is critical to limiting the use of unnecessary antibiotics. It is common practice for many
physicians to prescribe antibiotics and leave it to the patient’s discretion whether to fill the
prescription or not, regardless of a negative RADT. In this situation, the patient is highly likely to fill
the prescription and take the antibiotics with the hope of feeling better. Complicating the decision
further is the fact that while GAS pharyngitis is a self-limiting condition, regardless of antibiotic
administration,11 antibiotics are also given to prevent the development of long-term rheumatic
complications. It should be noted, however, that antibiotics remain effective for prevention of these
sequelae even if withheld up to 9 days after the initiation of symptoms.11 Therefore, waiting for the
culture results to finalize before prescribing antibiotics may be an effective method for decreasing
unnecessary antibiotic prescriptions.

References

1. Shulman ST, Bisano AL, Clegg HW, et al. Clinical Practice Guideline for the Diagnosis and
Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society
of America. Clin Inf Dis. 2012; 55(10): e86-e102.

2. Ebell MH, Smith MA, Barry HC, Ives K, Carey M. The rational clinical examination. Does this
patient have strep throat? JAMA. 2000; 284:2912–8.

3. McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical validation of guidelines for
the management of pharyngitis in children and adults. JAMA 2004; 291:1587–95.

4. Gerber MA. Diagnosis of pharyngitis: methodology of throat cultures. In: Shulman ST, ed.
Pharyngitis: management in an era of declining rheumatic fever. New York: Praeger, 1984:61–72.

5. Brien JH, Bass JW. Streptococcal pharyngitis: optimal site for throat culture. J Pediatr. 1985;
106:781–3.

6. Kellogg JA. Suitability of throat culture procedures for detection of group A streptococci and as
reference standards for evaluation of streptococcal antigen detection kits. J Clin Microbiol. 1990;
28:165–9.

7. Gerber MA, Shulman ST. Rapid diagnosis of pharyngitis caused by group A streptococci. Clin
Microbiol Rev. 2004; 17:571–80.

8. Tanz RR, Gerber MA, Kabat W, Rippe J, Seshadri R, Shulman ST. Performance of a rapid antigen-
detection test and throat culture in community pediatric offices: implications for management of
pharyngitis. Pediatrics. 2009; 123:437–44.

9. Nyquist AC, Gonzales R, Steiner JF, Sande MA. Antibiotic prescribing for children with colds,
upper respiratory tract infections, and bronchitis. JAMA. 1998; 279:875–7.

10. Pelucchi C, Grigoryan L, Galeone C, et al. Guideline for the management of acute sore throat.
Clin Microbiol Infect. 2012; 18 (Suppl 1): 1-27.

11. Brink WR, Rammelkamp CH Jr, Denny FW, Wannamaker LW. Effect in penicillin and
aureomycin on the natural course of streptococcal tonsillitis and pharyngitis. Am J Med. 1951; 10:300.

30. Catanzaro FJ, Stetson CA, Morris AJ, et al. The role of the streptococcus in the pathogenesis of
rheumatic fever. Am J Med. 1954; 17:749.

Copyright © 2014 the Alliance for the Prudent Use of Antibiotics (APUA) 120001636 11/14