Emergency Department Treatment of Pharyngitis in Children

ED Management of Acute Pharyngitis in Infants and Children

No Sore throat/acute pharyngitis in ED? Clinical judgment

Yes Yes Obvious signs/sx GABHS1? Treat2

No Yes Rapid test3 POSITIVE? Treat2

Submit throat cx4 (treatment pending results) Obtain Heterophile Antibody Test if suspect infectious mononucleosis

Notes:

1. Signs/sx GABHS (group A beta-hemolytic streptococcus or Streptococcus pyogenes) may include: fever, exudative pharyngitis, palatal petechiae, strawberry tongue, circumoral pallor, scarletiniform rash, Pastia’s lines (non- blanching areas of hyperpigmentation in antecubital fossae) 2. Acceptable treatment regimens for GABHS pharyngitis: (Note: AVOID macrolides due to GABHS resistance) PCN VK 50 mg/kg/day PO div BID X 10 days (DRUG OF CHOICE) Amoxicillin 50 mg/kg/dose PO QD X 10 days C-R bicillin (900/300) 1,200,000 units IM X 1 dose (Note: this is far less painful than Bicillin LA and 1,200,000 units can be given to any child weighing < 64 kg) Cefpodoxime 5 mg/kg/dose PO BID X 5 days Cefuroxime axetil 20 mg/kg/day PO div BID X 4 days Cefdinir 7 mg/kg/dose (up to 300 mg) PO BID X 5 days Clindamycin 10 mg/kg/dose (up to 450 mg) PO TID X 10 days (anaphylaxis to PCN) 3. Rapid tests have generally > 90% sensitivity (i.e. if high colony counts) and > 95% specificity for the diagnosis of GABHS against blood agar plate. 4. Throat cx (blood agar plate) is recommended as a back-up of negative rapid test results due to low sensitivity of rapid tests in the setting of low GABHS colony counts. A single throat cx has a documented sensitivity between 90% and 97%.

Guideline for ED Treatment of Acute Pharyngitis in Children References:

Krober MS, Weir MR, Themelis NJ, van Hamont JE. Optimal dosing interval for penicillin treatment of streptococcal pharyngitis. Clin Pediatr 1990;29:646-648 [BID dosing of oral PCN results in bacteriologic treatment failure rates comparable to a QID dosing schedule]

Pichichero ME, Gooch WM, Rodriquez W, Blumer JL, Aronoff SC, Jacobs RF, Musser JM. Effective short-course treatment of acute group A beta-hemolytic streptococcal tonsillopharyngitis. Ten days of penicillin V vs 5 days or 10 days of cefpodoxime therapy in children. Arch Pediatr Adolesc Med 1994;148:1053-1060 [Cefpodoxime 5 mg/kg/dose BID for 5 days resulted in significantly lower bacteriologic treatment failure rates than PCN given QID for 10 days]

Aujard Y, Boucot I, Brahimi N, Chiche D, Bingen E. Comparative efficacy and safety of four-day cefuroxime axetil and ten-day penicillin treatment of group A beta-hemolytic streptococcal pharyngitis in children. Pediatr Infect Dis J 1995;14:295-300 [A 4 day treatment regimen with cefuroxime axetil was as effective and well tolerated as a 10 day treatment regimen with PCN VK for GABHS pharyngitis]

Tack KJ, Hedrick JA, Rothstein E, Nemeth MA, Keyserling C, Pichichero ME. A study of 5-day cefdinir treatment for streptococcal pharyngitis in children. Cefdinir Pediatric Pharyngitis Study Group. Arch Pediatr Adolesc Med 1997;151:45-49 [A 5 day regimen of cefdinir eradicated a higher proportion of GABHS than a 10 day regimen of PCN VK but no difference was noted between the regimens for clinical outcomes or adverse event rates]

Bisno AL, Gerber MA, Gwaltney JM, Kaplan EL, Schwartz RH: Diagnosis and management of Group A streptococcal pharyngitis: a practice guideline. Clin Infect Dis 1997;25:574-583

Macris MH, Hartman N, Murray B, Klein RF, Roberts RB, Kaplan EL, Horn D, Zabriskie JB. Studies of the continuing susceptibility of group A streptococcal strains to penicillin during eight decades. Pediatr Infect Dis J 1998;17:377-381 [To date there have been no penicillin-resistant isolates of GABHS worldwide and the MIC of penicillin for GABHS has not changed]

Feder Jr HM, Gerber MA, Randolph MF, Stelmach PS, Kaplan EL. Once-daily therapy for streptococcal pharyngitis with amoxicillin. Pediatrics 1999;103:47-51 [Once-daily amoxicillin therapy is as effective as penicillin VK therapy given TID for GABHS pharyngitis]

Tanz RR. Convenient schedules and short course treatment of acute streptococcal pharyngitis. Pediatr Infect Dis J 2000;19:569-570

Guideline for ED Treatment of Acute Pharyngitis in Children [Summary of current therapeutic regimens for treatment of GABHS pharyngitis]

Guideline for ED Treatment of Acute Pharyngitis in Children