Evidence-Based Medicine for Student Health Services
Robert J. Flaherty, MD
Swingle Student Health Service
Montana State University
Bozeman, MT 59717
Pharyngitis/Tonsillitis
 
Etiology Monitoring
Epidemiology Prognosis
Diagnosis Prevention
Treatment Patient Education
General Information

EBM for Student Health
    Home Page

About EBM

EBM Resources

Specific Conditions/Diseases

 
Etiology
No evidence is cited. 

Epidemiology
No evidence is cited. 

Diagnosis
Clinical Diagnosis
A scoring system was developed using Bayes Theorem to allow for adjustment for the prevalence of Group A Beta-Hemolytic Streptococcal (GABHS) pharyngitis in the community. The following significantly favored positive throat culture: autumn season; age <11 years; duration < 3 days; very sore throat; sore to swallow; bad smell from breath; absence of sore ears and cough; fever; myalgia; flushed; very enlarged or tender glands; exudate; and mouth red or ulcerated. The prevalence of GABHS may be difficult to determine and the resulting predictions were only slightly better than general practitioners' opinions. Evidence from randomized trials was not found for most questions related to the management of sore throats. Four clinical characteristics (no cough, fever higher than 38 degrees C, exudate, and tender cervical nodes) suggest that a case of pharyngitis would be improved by antibiotic treatment. Use of a clinical score for management of GABHS pharyngitis can be recommended on the basis of the rarity of rheumatic fever in modern society, the resources devoted to management of upper respiratory tract illnesses, the volume of antibiotics prescribed, and the emergence of antibiotic resistance as a growing health issue. Laboratory Diagnosis
In a setting with adherent patients, children with sore throats should generally get throat cultures in lieu of rapid streptococcus antigen tests.



Treatment
Antibiotics 
Antibiotics confer a relative benefit, albeit modest, in the treatment of sore throat (both GABHS and non-GABHS pharyngitis/tonsillitis). In modern Western society the incidence of acute rheumatic fever may not be high enough to justify the routine use of antibiotics for sore throat. Protecting sore throat sufferers against suppurative complications (otitis media, pharyngitis, quinsy) can only be achieved by treating many with antibiotics who will derive no benefit. Antibiotics shorten the duration of symptoms, but by a mean of only about half of one day.


Penicillin administered BID is as efficacious as TID or QID dosing in the treatment of streptococcal tonsillopharyngitis. This study also demonstrates that QD penicillin is less efficacious than TID or QID dosing. Simplified regimens of amoxicillin
of shorter duration or of less frequent dosing should be further investigated.


Amoxicillin 1gram bid x 6 days is as effective as penicillin V 500mg tid x 10d in the treatment of Group A Beta-Hemolytic Streptococcal pharyngitis, with respect to eradication of GABHS, long term cure and incidence of side effects. Cost is equivalent and sore throat may resolve quicker on amoxicillin.

Cefadroxil monohydrate (Duricef) is an excellent alternative to oral penicillin V in the treatment of GABHS pharyngitis and tonsillitis. It is also much more expensive. Cefprozil, cefpodoxime proxetil, loracarbef, cefixime, and ceftibuten were compared to conventional antibiotic therapies (usually amoxicillin/clavulanate, cefaclor or cephalexin) for community acquired infections. Infections included acute otitis media, pharyngitis, sinusitis, bronchitis, pneumonia, urinary tract infection and skin and skin-structure infections. The newer agents appear to be as clinically effective as conventional therapies (but not more effective) for the treatment of common community-acquired infections. They may also have the potential to improve compliance due to their once/twice daily mode of
administration. 
  • Caveats
    • Age group studied: Unknown
    • Sample Size: Analytical review of studies: acute otitis media: 19 studies, pharyngitis: 13 studies, sinusitis: 4 studies, bronchitis: 10 studies, pneumonia: 7 studies, urinary tract infection: 11 studies, skin and skin-structure infections: 4 studies. Most studies consisted of 30-50 patients in each arm
    • Population: Unknown
    • Outcome measure: Clinical response to therapy
    • For some of these infections other studies show that there is no evidence that any antibiotic therapy is beneficial
  • Citations
Receiving a prescription for an antibiotic for a URI was not associated with increased patient satisfaction. Better to spend time explaining the nature of a particular illness and the physician's choice of treatment.



Monitoring
No evidence is cited.

Prognosis
No evidence is cited. 

Prevention
No evidence is cited. 

Patient Education
The following patient education materials are consistent with the available evidence.

Rev. 12/6/00

This Web site developed and maintained by Robert J. Flaherty, MD.
Comments, additions and corrections are encouraged.