Pharyngitis Michele Morrison BS RN CCRN - PowerPoint Presentation

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Pharyngitis

Michele Morrison BS RN CCRN

State University of New York Polytechnic Institute

Family Primary Health Care I

October 2016

Slide2

What is pharyngitis?

Inflammation of the pharynx

“Sore throat”

Can be infectious, does not have to be

(

Dunphy

,

Winland

-Brown, Porter, & Thomas, 2011)

Slide3

Etiology

Caused by viral infection

Measles

Adenovirus (common cold)

Chickenpox

Croup

Influenza

MononucleosisHIVRhinovirusCoronavirusCocksackie virus

Caused by bacterial infection

Group A beta hemolytic streptococcusGonorrheaChlamydiaCorynebacteriumDiptheriaMycoplasma pneumoniaePertussisTonsillitisOther cause:Second-hand smokeKawasaki disease

(Martel &

Cherney

, 2015)

(

Dunphy

,

Winland

-Brown, Porter, & Thomas, 2011)

Slide4

Pathophysiology

Infective cause enters pharyngeal mucosa

Inflammation

Nasal secretions

(

Dunphy

,

Winland-Brown, Porter, & Thomas, 2011)

Slide5

Incidence

11 million people annually

Adults 2x/year

Children 5x/year40-60% viral

15% strep

10% strep in adults (once every 8 years)

20-30% strep in children (once every 4 years)

Increased occurrence during colder weather (30%)(Linder, Chan, & Bates, 2006)

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Screening and Risk Factors

Screening

Assess if high risk patient for strep pharyngitis

History of rheumatic fever

Close contact with person with history of rheumatic fever

AHRQ algorithm

Modified

Centor ScoreRisk Factors

Frequent cough

Exposure to inhaled toxins (exhaust, cleaning fluids)Illnesses that cause pharyngitisEnvironmental allergiesSmokeImmunocompromisedIncreased stressAlcohol in excessAge (5-15)(Dunphy, Winland-Brown, Porter, & Thomas, 2011)

(Clinical Alignment and Performance Excellence University of Michigan, 2013)

(

Karla, Higgins, & Perez,

2016)

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(Bisno, Gerber, Gwaltney, Kaplan, & Schwartz, 2002)

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(Clinical Alignment and Performance Excellence University of Michigan, 2013)

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(Clinical Alignment and Performance Excellence University of Michigan, 2013)

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Modified Centor

Score

http://www.mdcalc.com/modified-centor-score-for-strep-pharyngitis/

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Clinical Findings

Sore throat

Scratchy throat

Throat redThroat edemaThroat white spots or exudate

Difficulty swallowing

Painful swallowing

(U.S. Department of Health and Human Services, 2013)

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Clinical Findings

Fever

Swollen tonsils

Tonsillar exudateAnterior cervical lymphadenopathyCervical lymph node tenderness

NO

cough, conjunctivitis, rhinorrhea if bacterial

(U.S. Department of Health and Human Services, 2013)

(Vincent, Celestin, & Hussain, 2004)

Slide13

Clinical Findings

Group A Streptococcus Pharyngitis

Pharyngeal swelling

Tonsillar swelling

Petechiae

on palate

Anterior cervical lymphadenopathy

(Vincent, Celestin, & Hussain, 2004)

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Differential Diagnosis

VIRAL INFECTIONS

Measles

Adenovirus (common cold)

Chickenpox

Croup

Influenza

MononucleosisHIVRhinovirusCoronavirusCocksackie virus

(Martel & Cherney, 2015)

(Dunphy, Winland-Brown, Porter, & Thomas, 2011)

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Differential Diagnosis

BACTERIAL INFECTIONS

Group A beta hemolytic streptococcus

Gonorrhea

Chlamydia

Corynebacterium

Diptheria

Mycoplasma pneumoniaePertussisTonsillitis

(Martel & Cherney

, 2015)(Dunphy, Winland-Brown, Porter, & Thomas, 2011)

Slide16

Social and Environmental Considerations

Humans only reservoirs for group A strep

Direct contact with infected person

Saliva, nasal discharge

2-5 day incubation

Crowded areas

Generally not infectious after 24 hours of antibiotics

Stay home until afebrile for 24 hours(Centers for Disease Control and Prevention, 2016)

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Laboratory Tests and Diagnostics

Rapid antigen/rapid strep

Throat culture

Monospot test

(Vincent, Celestin, & Hussain, 2004)

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Management

Pharmacological Treatment

Cough suppressant

Acetaminophen

Positive for Group A Strep

Antibiotics

(Centers for Disease Control and Prevention, 2016)

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Management

Antibiotics for streptococcus pharyngitis

Penicillin V: Children 250 mg

po

2-3 times/day x 10 days

Adults 250 mg

po 4 times/day x 10 daysAmoxicillin: 50 mg/kg once daily x 10 daysPenicillin G: < 27 kg 600,000 units x 1 dose

> 27 kg 1,200,000 units x 1 doseNo reports of resistance to penicillin or amoxicillin

Resistance noted to azithromycin and clarithromycin(Centers for Disease Control and Prevention, 2016)

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Management

Antibiotic therapy with penicillin allergy

Cephelexin

: 20 mg/kg/dose

po

BID max 500 mg/dose x 10 days

Cefadroxil

: 30 mg/kg/dose (max 1 GM) po once daily x 10 daysClindamycin: 7 mg/kg/dose po TID max 300 mg/dose x 10 days

Azithromycin: 12 mg/kg (max 500) po once daily x 5 days

Clarithromycin: 7.5 mg/kg/dose (max 250/dose) po BID x 10 days(Centers for Disease Control and Prevention, 2016)

Slide21

Management

Non-pharmacological Treatment

Warm salt-water gargle

Humidifier

Fluids

Rest

Hot tea with honey and lemon

(Linder, Chan, & Bates, 2006)

Slide22

Treatment Guidelines

Viral

Warm salt-water gargle

Acetaminophen

Bacterial

Antibiotics

Surgery may be indicated to remove tonsils if associated with chronic infection

Slide23

Treatment Guidelines

Infectious Disease Society of America

Guidelines for initiating antibiotic therapy

Patients at high risk for Group A strep – rapid antigen

If rapid antigen positive – start antibiotics

If rapid antigen negative – throat culture

If throat culture positive – antibiotic therapy

(Bisno, Gerber, Gwaltney, Kaplan, & Schwartz, 2002)

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Complications

Rheumatic fever

Scarlet fever

Peritonsillar abscessGlomerulonephritis

Infectious mononucleosis – airway obstruction

(Linder, Chan, & Bates, 2006)

Slide25

Follow-up

Worsening symptoms

Symptoms do not resolve

Recurrence

(Karla, Higgins, & Perez, 2016)

Slide26

Counseling and Education

Avoid triggers (smoking, alcohol, crowded areas, contact with infected people)

Take full course of antibiotics

Use back-up contraception if on oral contraception and antibiotics

Incubation period 2-5 days

Transmitted via saliva and nasal secretions

Hand washing

(Centers for Disease Control and Prevention, 2016)

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Consultation and Referral

Laryngoscopy if recurrent

ENT Consult if recurrent

(Vincent, Celestin, & Hussain, 2004)

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Multiple Choice Questions

Which symptoms are associated with viral infectious causes of pharyngitis?

cough, diarrhea, rhinorrhea

Tonsillar exudate

Anterior cervical adenopathy

Positive throat culture

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Answer

cough, diarrhea, rhinorrhea

These are common symptoms associated with viral pharyngitis.

The other choices are all associated with bacterial pharyngitis.

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Multiple Choice Questions

2. Which is not a common cause of pharyngitis?

Group A streptococcus

Anemia

Adenovirus

Cocksackie

virus

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Answer

B. Anemia

Anemia is not known to cause pharyngitis

Group A streptococcus is a common bacterial cause of pharyngitis

Adenovirus and

cocksackie

virus are common viral causes of pharyngitis

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Multiple Choice Questions

3. What is the recommended first line treatment for group A streptococcus pharyngitis?

Cephelexin

Azithromycin

Penicillin

Levofloxacin

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Answer

C. Penicillin

Penicillin is the first choice for treatment of group A streptococcus pharyngitis

Cephalexin and azithromycin are options if the patient has an allergy to penicillin

Levofloxacin is not recommended for the treatment of group A streptococcus pharyngitis

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Multiple Choice Questions

4. Who is more likely to test positive for group A streptococcus pharyngitis?

A 65 year old male with a cough and sore throat

An 8 year old female with a fever and sore throat

A 35 year old female with a sore throat and is a current every day smoker

A 3 year old male with a sore throat with white patches on their tonsils

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Answer

B. An 8 year old with fever and sore throat

Group A streptococcus pharyngitis is most common in children 5-15 years and is associated with fever

Patients 65 years old are unlikely to have group A strep and a cough is likely to have a viral cause

A 35 year old is less likely to have group A strep and smoking is a cause of non-bacterial pharyngitis

Positive group A strep is rare in a 3 year old

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Multiple Choice Questions

Which is a recommended treatment for pharyngitis with presumed viral etiology?

Hot tea with honey and lemon

Antibiotics

Laryngoscopy

Surgery

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Answer

Hot tea with honey and lemon

Supportive therapy is recommended for viral pharyngitis

Antibiotics are not effective against viral infections

Laryngoscopy and surgery are invasive and would not be warranted for a viral pharyngitis which is typically self-limiting

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Multiple Choice Questions

6. What is the pathophysiology that causes pharyngitis?

Pharyngitis is not real, patients report having a sore throat to get out of work

An infectious agent invades the pharyngeal mucosa causing irritation and inflammation

Pharyngitis is only associated with tobacco use

Pharyngitis is only associated with throat cancer

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Answer

Pharyngitis is caused by an infectious agent that invades the pharyngeal mucosa

Pharyngitis is a real diagnosis that is very common

Tobacco and throat can cancer can increase the incidence of pharyngitis but are not the only cause

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Multiple Choice Questions

7. Group A streptococcus pharyngitis has been reported to have isolated strains resistant to which antibiotic?

Penicillin

Azithromycin

Amoxicillin

Clindamycin

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Answer

B. Azithromycin

Group A streptococcus pharyngitis is only known to have strains resistant to azithromycin and clarithromycin

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Multiple Choice Questions

Which is a complication of untreated group A streptococcus pharyngitis?

Typhoid fever

Yellow fever

Rheumatic fever

Cabin fever

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Answer

C. Rheumatic fever

Rheumatic fever is a known complication of untreated group A streptococcus

Group A streptococcus is not associated with typhoid fever or yellow fever

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Multiple Choice Questions

Which is not a risk factor for group A streptococcus pharyngitis?

Age 5-15 years

Immunocompromised patient

Contact with person infected with group A strep

Age 65 years and older

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Answer

D. Age 65 years and older

The age group at highest risk for group A streptococcus is 5-15 years

Immunosuppression and contact with people infected with group A strep increase the risk of becoming infected with group A strep

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Multiple Choice Questions

Which is a screening tool that can be used as a guide for testing and treatment of pharyngitis?

Modified

Centor

Score

Pharyngeal Assessment Tool

Brown’s Sore Throat Measurement

Wagner’s Strep Swallow Assessment

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Answer

Modified

Centor

ScoreThe Modified

Centor

Score was developed by Dr.

Centor

as a tool to determine patients at high risk for group A strepThe other choices are not recognized assessment tools for pharyngitis

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THANK YOU!

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References

Centers for Disease Control and Prevention. (2016). Pharyngitis (strep throat). Retrieved from http://www.cdc.gov/groupastrep/diseases-hcp/strep-throat.html

Clinical

Alignment and Performance Excellence University of Michigan. (2013). Pharyngitis guidelines for clinical care: Ambulatory. Retrieved from http://www.med.umich.edu/1info/FHP/practiceguides/pharyngitis/pharyn.pdf

Dunphy

, L. M.,

Winland

-Brown, J. E., Porter, B. O., & Thomas, D. J. (2011). Primary care: The art and science of advanced practice nursing (3rd ed.). Philadelphia, PA: F.A. Davis Company.

Karla, M. G., Higgins, K. E., & Perez, E. D. (2016). Common questions about streptococcal pharyngitis. American Family Physician,

94(1), 24-31. Retrieved from www.aafp.org/afpLinder, J. A., Chan, J. C., & Bates, D. W. (2006). Evaluation and treatment of pharyngitis in primary care practice. Journal of American Medical Association, 166, 1374-1379. Retrieved from www.archinternmed.com

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References

Martel, J., &

Cherney

, K. (2015). Pharyngitis. Retrieved from http://www.healthline.com/health/pharyngitis

U.S

. Department of Health and Human Services. (2013). Pharyngitis. Retrieved from https://

www.guideline.gov/summaries/summary/46947/pharyngitis

Vincent, M. T., Celestin, N., & Hussain, A. N. (2004). Pharyngitis. American Family Physician, 69(6), 1465-1470. Retrieved from http://www.aafp.org/afp/2004/0315/p1465.html