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GPAC: Guidelines and Protocols Advisory Committee Sore Throat - Diagnosis and Management Effective Date: March 2003 Summary | Flow Sheet | Patient Guide | Full Guideline in PDF Recommendations and TopicsScopeThis guideline applies to patients three years of age and older presenting with sore throat. It provides recommendations for performing throat swabs and prescribing antibiotics. The desired outcomes to be achieved through this guideline are:
Approximately 10 to 20 per cent of patients with sore throat have an infection caused by group A beta-hemolytic streptococcus (strep throat). A small percentage of sore throats will be caused by a variety of other bacterial organisms (e.g., Group C and G streptococcus) or disease processes (e.g., lymphoma). However, most patients have viral infections and benefit from symptomatic treatment alone. Although many viruses cause sore throat, Epstein-Barr virus (EBV) is singled out in this guideline because of the rare but potentially fatal complication of splenic rupture. In a previously well individual with a sore throat the first priority is to distinguish between viral and strep infection.  RECOMMENDATION 1: Throat swab for culture: when and howA throat swab should be taken when a diagnosis of strep throat is suspected from the clinical and epidemiological findings (see Table 1 above) and the patient is not already taking antibiotics. Technique: Using a sterile throat swab, contact the posterior pharyngeal wall and the surface of both tonsils, then place in an appropriate transport medium for prompt delivery to the laboratory. A culture is usually the only test required. However, antibiotic sensitivity should also be requested in penicillin allergic patients due to the emergence of erythromycin resistant strains of streptococcus. A culture is not indicated following a course of antibiotics for strep throat unless symptoms persist. Asymptomatic contacts of a patient with strep throat do not require cultures or empiric antibiotics. RECOMMENDATION 2: Antibiotics: when and whichAntibiotics should not be prescribed until the culture result confirms strep throat or another treatable bacterial pathogen. Immediate administration of antibiotics should be considered only when patients are very ill, culture results will be delayed more than 72 hours, or patient follow-up will be difficult. Antibiotics should be discontinued if the culture result is negative. RECOMMENDATION 3: Suspected Epstein-Barr virus (EBV) infectionIf EBV infection is suspected it may be confirmed by:
Although difficult to identify clinically, splenic enlargement may occur in EBV infection increasing the risk of rupture, both spontaneous and traumatic. Therefore, it is prudent to recommend avoidance of vigorous activity for four weeks after the onset of clinical illness. RationaleSore throat is one of the most frequent illnesses for which primary care physicians and pediatricians are consulted. However, only approximately 10 to 20 per cent of patients will have strep throat. Moreover, the signs and symptoms of group A streptococcal and nonstreptococcal pharyngitis overlap so broadly that accurate diagnosis on clinical grounds alone is usually impossible. Scoring systems to assist in decisions about when to obtain a culture have been developed by a variety of investigators. However, these scoring systems require further evaluation. With the exception of rare infections by certain pharyngeal bacterial pathogens (e.g., Corynebacterium diphtheriae, Neisseria gonorrhoeae and Arcanobacterium haemolyticum), antimicrobial therapy is of no proven benefit in the treatment of acute pharyngitis due to bacteria other than group A streptococcus. It is therefore extremely important that physicians properly establish the diagnosis of strep throat to prevent inappropriate administration of antimicrobials to large numbers of patients with pharyngitis. The inappropriate administration of antimicrobials leads to unnecessary expense and exposes patients to the hazards of antimicrobials. It may also contribute to the emergence of antibiotic resistant organisms. If a diagnosis of strep throat is established, the clinician should select the most appropriate antimicrobial with respect to specificity, compliance, safety and cost. Viral infections cause the majority of sore throats. Epstein-Barr virus (EBV) is just one of many viruses that can cause sore throats. EBV infection may be considered from clinical features such as hepatosplenomegaly and generalized lymphadenopathy. Most cases can be treated symptomatically. More severe cases, with upper airway obstruction or hepatosplenomegaly, may require additional precautions and treatments. The monospot slide test is sensitive, specific and easily performed. Approximately 85-90 per cent of patients will show positive results by the third week of illness. However, test results may be negative early in the course of illness. The monospot test is unreliable in children younger than four. In these young patients EBV serology is the test of choice. However, its usefulness is limited by the much longer time it takes to get results. References
SponsorsThis guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association and adopted by the Medical Services Commission. Funding for this guideline was provided in full or part through the Primary Health Care Transition Fund. Revised Date: April 1, 2007This guideline is based on scientific evidence current as of the effective date. The principles of the Guidelines and Protocols Advisory Committee are to:
DisclaimerThe Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. PDF Format Some documents on this Web site are in PDF format and require a PDF reader. If you do not have Adobe Acrobat Reader Version 7.0 or the most recent version of another PDF reader, you can download Adobe Acrobat Reader by clicking on the 'Get Acrobat Reader' icon.
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