Pharyngitis

Front 1

What are the aims of infection guidance?

Back 1

1. Provide a simple, empirical approach to the treatment of common infections 2. Pomote the safe, effective and economic use of antibiotics 3. Minimise the emergence of bacterial resistance in the community

Front 2

What are the principles of treating common infections in the community?

Back 2

Only prescribe A/B's likely a clinical benefit. Consider no/delayed A/B treatments for acute URTI inf. Use simple generic A/Bs where possible Avoid broad spectrum Avoid widespread topical A/B's use. In Pregnancy AVOID - Tetracyclines - Aminoglycosides - Quinolones or High Dose Metronidazole (>2g).

Front 3

What alternative A/B strategies should be considered in acute URTI infections in general practice?

Back 3

No OR Delayed A/B strategy

Front 4

Which A/B Classes should be avoided in Pregnancy?

Back 4

In Pregnancy AVOID - Tetracyclines - Aminoglycosides - Quinolones - High Dose Metronidazole (>2g). “To Offer Aminoglycosides Hurtsâ€

Front 5

What treatment decision aids are used for A/B use in Tonsillitis/Pharyngitis? For which patients are they valid?

Back 5

Centor Criteria (Adults) FeverPAIN score.

Front 6

What is/are the Centor Criteria? What management does it dictate?

Back 6

Screen for likely Group A streptococcal infection or Streptococcal Pharyngitis in adult patients. Application of CC to Children appears to be ineffective. Negative Predictive Value of circa 80% (i.e. Good for ruling out, not ruling in). History of fever +1 Tonsillar exudates +1 Tender anterior cervical adenopathy +1 Absence of cough +1 (Unofficially - Hx of Otits Media = +1) Modified Centor Criteria (not really used) <15yrs +1 >44yrs -1 Management (Pure Centor) 1= Strep Risk <10% No A/B. No Throat Culture. Give Paracetamol + Supportive Tx 2-3 = Strep Risk 15% Throat Culture +/- A/B based on Culure 4 = Strep Risk 55% Give Empirical A/B. No Culture.

Front 7

What is the FeverPain score?

Back 7

Risk of GAS in tonsillitis/pharyngitis. /Need for A/B's Can be used for ≥3yrs The score consist of five items: 1. Fever during previous 24 hours; 2. Purulence; 3. Present ≤3 days 4. Very Inflamed tonsils; 5. No cough/coryza (FeverPAIN)

Front 8

Clinical Features of Pharyngitis/Tonsillitis?

Back 8

Examination along will not distingush between pathogens Sore throat when swallowing (Odonophagia) Fever (esp. In Bacterial Infection) Headache Malaise Lymphadenopathy (Anterior Neck Pain) Likely Bacterial = Fever, Headache, Malaise Likely Viral = Signs of URTI (Cough, congestion, sinusitis, ear pain) Serious Symptoms Secretions, drooling, dysphonia, muffled "hot potato" voice, or neck swelling, difficulty swallowing.

Front 9

What dangerous conditions should be ruled out for patient with serious symptoms of pharyngitis/tonsillitis?

Back 9

Serious Symptoms Secretions, drooling, dysphonia, muffled "hot potato" voice, or neck swelling, difficulty swallowing. Conditions Epiglottitis – Severity of sore throat out of proportion to the oropharygneal exam. Peritonsillar Abscess – Visually, Trismus, reflex spasm of pterygoid (2/3) Submandibular Infection – E.g. Ludwigs Angina, fever, chills, and malaise. Leaning forward to max airway, no lymph, submand woody induration, tender, orofloor erythema+elevation. Retropharyngeal Infections – Common in penetrating trauma e.g. Chicken bone. Primary HIV – Sore throat is common manifestation of acute HIV infection. Painful mucocutaneous ulceration along with other signs of inf, fever, adenopathy, faigue, rash.

Front 10

Discuss the diagnostic tests available for evaluation of pharyngitis/tonsillitis?

Back 10

Rapid Antigen Detection Test Used for identification of GAS. Indicated for patients with a centor score of ≥3 Postive RADT = Rapid A/B initiation. Sensitivity = 70-90%, Specificity = 90-100% Throat Culture Gold Standard but slow 24-48hrs to culture Primarily used as back-up where GAS suspicion high Also standard in vulnerable groups, even if RADT -ve e.g. Immunocomp, Steroids users, Poor DM. DNA Probes Rarely but 95% spec+sens. Alternative to throat culture

Front 11

Discuss the Management of Patients who are do have non-GAS pharyngitis/tonsillitis.

Back 11

Pharyngitis will resolve in a few days (circa 8) w/o sequelae and no further diagnostic measures are required. Symptomatic treatment should be offered. - Systemic Analgesia (Aspirin, acetaminophen, NSAIDs (ibuprofen best). - Sucked Lozenges/Tablets (OTC or Medicated e.g. Lidocaine) - Phenol Sprays (less evidence) - Controversial. Glucocorticoids. None unless severe swelling.

Front 12

Discuss the antimicrobial treatment of step throat in adults and children.

Back 12

Emprical Antibiotic treatment is indicated for: - Patients with high clincial suspicion (Centor ≥3) - Patients with a +ve RADT/Throat Culture Adults Oral Penicillin V (Phenoxymethylpenicillin) 10 days 333-666 QDS If allergic: Clarithromycin 5 days 250-500 BD Children Phenoxymethylpenicillin suspension 7-10 days(variable doses) If Allergic: Erythromycin or Clarithromycin. Note: Amoxicillin often used since it is more palatable orally. Intramuscular penicillin G benzathine may be administered to patients who cannot complete a 10-day course of oral therapy.