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  • Centor criteria for streptococcal pharyngitis: exudate or swelling on tonsils, anterior cervical adenopathy, fever, lack of cough.

  • Goal is to treat group A beta-hemolytic streptococcal infection to prevent subsequent rheumatic fever (rash, arthralgias, myocardtis) and other sequelae (glomerulonephritis, posterior pharyngeal abscess).


Pharyngitis and tonsillitis account for over 10% of all office visits to primary care clinicians and 50% of outpatient antibiotic use. The main concern is determining who is likely to have a group A beta-hemolytic streptococcal (GABHS) infection, since this can lead to subsequent complications, such as rheumatic fever and glomerulonephritis. A second public health policy concern is reducing the extraordinary cost (both in dollars and in the development of antibiotic-resistant S pneumoniae) in the United States associated with unnecessary antibiotic use. Numerous well-done studies and experience with rapid laboratory tests for detection of streptococci (eliminating the delay caused by culturing) have informed a consensus recommendation.


A. Symptoms and Signs

The clinical features most suggestive of GABHS pharyngitis include fever over 38°C, tender anterior cervical adenopathy, lack of a cough, and pharyngotonsillar exudate (Figure 8–9). These four features (the Centor criteria), when present, strongly suggest GABHS. When two or three of the four are present, there is an intermediate likelihood of GABHS. When only one criterion is present, GABHS is unlikely. Sore throat may be severe, with odynophagia, tender adenopathy, and a scarlatiniform rash. An elevated white count and left shift are also possible. Hoarseness, cough, and coryza are not suggestive of this disease. It is also rare to have GABHS in individuals younger than 3 years old.

Figure 8–9.

Marked exudative pharyngitis and tonsillitis due to group A beta-hemolytic streptococci. (Used, with permission, from Lawrence B. Stack, MD, in Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine, 5th ed. McGraw Hill, 2021.)

Marked lymphadenopathy and a shaggy, white-purple tonsillar exudate, often extending into the nasopharynx, suggest mononucleosis, especially if present in a young adult. With about 90% sensitivity, lymphocyte-to-white-blood-cell ratios of greater than 35% suggest EBV infection and not tonsillitis. Hepatosplenomegaly and a positive heterophile agglutination test or elevated anti-EBV titer are corroborative. However, 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 that might be misinterpreted by the patient as a penicillin allergy. Diphtheria (extremely rare but described in persons with alcohol use disorder) presents with low-grade fever and an ill patient with a gray tonsillar pseudomembrane.

The most common pathogens other than GABHS in the differential diagnosis of “sore throat” are viruses, Neisseria gonorrhoeae, Mycoplasma, and Chlamydia trachomatis....

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