Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content ++ Key Features ++ Essentials of Diagnosis ++ Sore throat Fever Anterior cervical adenopathy Tonsillar exudate Focus is to treat group A β-hemolytic streptococcus infection to prevent rheumatic sequelae ++ General Considerations ++ Group A β-hemolytic streptococci (Streptococcus pyogenes) are the most common bacterial cause of exudative pharyngitis The main concern is to determine whether the cause is group A β-hemolytic streptococcal infection (GABHS), because of the complications of rheumatic fever and glomerulonephritis A second public health policy concern is to reduce the extraordinary cost (in both dollars and the development of antibiotic-resistant Streptococcus pneumoniae in the United States associated with unnecessary antibiotic use) About one-third of patients with infectious mononucleosis have secondary streptococcal tonsillitis, requiring treatment Ampicillin should routinely be avoided if mononucleosis is suspected because it induces a rash ++ Demographics ++ Pharyngitis and tonsillitis account for > 10% of all office visits to primary care clinicians and 50% of outpatient antibiotic use ++ Clinical Findings ++ Symptoms and Signs ++ Centor diagnostic criteria Fever > 38°C Tender anterior cervical adenopathy Lack of cough Pharyngotonsillar exudate Sore throat may be severe, with odynophagia, tender adenopathy, and a scarlatiniform rash Hoarseness, cough, and coryza are not suggestive of this disease Marked lymphadenopathy and a shaggy white-purple tonsillar exudate, often extending into the nasopharynx, suggest mononucleosis, especially if present in a young adult ++ Differential Diagnosis ++ Viral pharyngitis Epstein-Barr virus (EBV)/infectious mononucleosis Primary HIV infection Candidiasis Necrotizing ulcerative gingivostomatitis (Vincent fusospirochetal disease) Retropharyngeal abscess Diphtheria Neisseria gonorrhoeae Mycoplasma Anaerobic streptococci Corynebacterium haemolyticum Epiglottitis ++ Diagnosis ++ Laboratory Tests ++ The presence of the four Centor diagnostic criteria strongly suggests GABHS When two or three of the four are present, there is an intermediate likelihood of GABHS When zero or one Centor criterion is present, GABHS is unlikely; throat culture or rapid antigen detection testing of throat swab is not necessary With about 90% sensitivity, lymphocyte to white blood cell ratios of > 35% suggest EBV infection and not tonsillitis ++ Treatment ++ Patients with zero or one Centor criteria should not receive antibiotics Patients with two or three Centor criteria whose throat cultures or rapid antigen detection testing show positive results should receive antibiotic treatment Patients who have four Centor criteria can receive empiric therapy without throat culture or rapid antigen detection testing ++ Medications ++ Benzathine penicillin intramuscular injection 1.2 million units once is optimal but painful Use for noncompliant patients Analgesic, anti-inflammatory drugs (aspirin, acetaminophen, corticosteroids) Oral antibiotics Penicillin V potassium (250 mg three times daily or 500 mg twice daily orally for 10 days) or cefuroxime axetil (250 mg twice daily orally, 5–10 days) Efficacy of 5-day penicillin V similar to 10-day course: 94% clinical response, 84% eradication... GET ACCESS TO THIS RESOURCE Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Username? Forgot Password? Sign in via OpenAthens Sign in via Shibboleth Get Free Access Through Your Institution Contact your institution's library to ask if they subscribe to McGraw-Hill Medical Products. Access My Subscription GET ACCESS TO THIS RESOURCE Subscription Options Pay Per View Timed Access to all of AccessMedicine 24 Hour $34.95 (USD) Buy Now 48 Hour $54.95 (USD) Buy Now Best Value AccessMedicine Full Site: One-Year Individual Subscription $995 USD Buy Now View All Subscription Options