© Borgis - New Medicine 4/2010, s. 17-129
*Elżbieta Mazur
Acute pharyngotonsillitis:
current diagnosis and treatment**
Medical Microbiology Department, Medical University of Lublin
Head of the Department: prof. Maria Kozioł-Montewka MSc, PhD
Summary
Although its etiology is viral in about 80% of cases, antibiotics are frequently prescribed in the treatment of pharyngotonsillitis. Inappropriate use of antibiotics is a major cause of bacterial resistance, particularly among respiratory pathogens. Many countries all over the world, including Poland, have national guidelines for the diagnosis and treatment of respiratory tract infections to minimize unnecessary antibiotic prescriptions. This review paper presents current diagnosis and treatment of acute pharyngotonsillitis according to Polish Recommendations 2010.
Introduction
Acute pharyngotonsillitis is an illness that often leads patients to consult general practitioners, pediatricians, internists and ear, nose and throat specialists and results in a high degree of absence from daycare, school and work. It can be caused by a wide variety of pathogens. Viruses account for 70-85% of pharyngotonsillitis cases in children over 3 years of age and for 90-95% of cases in adults (1). Rhinoviruses, coronaviruses, adenoviruses, Coxsackie A, influenza, parainfluenza, RSV and herpes family viruses all may cause pharyngotonsillitis (1-4). Bacteria are responsible for 15-30% of pharyngotonsillitis cases in children and for 5-10% of cases in adults (1, 5). Among them, the most important one is Streptococcus pyogenes (Streptococcus beta-hemolytic group A, GAS). Beta-hemolytic streptococci belonging to other groups (predominantly C and G) are detected less frequently (1, 6-8). Other bacteria cause acute pharyngotonsillitis only sporadically (1, 5).
Although its etiology is viral in about 80% of cases, antibiotics are frequently prescribed in the treatment of pharyngotonsillitis (1, 5, 9). Inappropriate use of antibiotics is a major cause of bacterial resistance, particularly among respiratory pathogens (1, 5, 10, 11). Antibiotic consumption in Poland proved to be one of the highest in comparison with other European countries. Also, the percentage of Streptococcus pneumoniae strains resistant to penicillin is soaring (1, 5). Bacterial resistance is currently recognized as a global health problem. Many countries all over the world, including Poland, have national guidelines for the diagnosis and treatment of respiratory tract infections to minimize unnecessary antibiotic prescriptions. The national recommendations differ from each other because the epidemiological situation in different countries varies (1, 3, 5, 12, 13).
Patients with streptococcal pharyngotonsillitis should be treated with antibiotics to prevent rheumatic fever and local complications such as peritonsillar abscess, mastoiditis and sinusitis (1, 2, 14-16). However, it is of utmost importance to prevent prescription of antibiotics for pharyngotonsillitis which is viral in origin (1, 2, 14). Therefore, the differentiation between bacterial pharyngotonsillitis and that of viral etiology is crucial (3, 5).
Clinical differentiation of streptococcal and viral pharyngotonsillitis
In general, the clinical features of GAS pharyngotonsillitis are not specific and cannot be easily differentiated from those of viral origin; therefore a diagnosis based only on clinical grounds is impossible. Various clinical and epidemiological factors may indicate higher probability of streptococcal etiology, but the diagnosis must be confirmed by laboratory methods. Epidemiologically GAS pharyngotonsillitis is often seen in children between 5 and 15 years of age and tends to occur in colder months of the year. Patients with GAS pharyngitis often complain of pain while swallowing, fever, enlarged cervical lymph nodes and fatigue. Headache, nausea, vomiting and abdominal pain may be seen, particularly in children. Tonsils are reddened and swollen. The roof of the mouth may have fine petechial lesions. Although none of these are specific for GAS pharyngotonsillitis, absence of fever or presence of clinical features such as cough, hoarseness, conjunctivitis, runny nose, viral exanthem and diarrhea are common symptoms of viral upper respiratory tract infections (1, 2, 14, 17).
The basic aim of clinical differentiation is to evaluate the likelihood of streptococcal etiology. Depending on the result of clinical examination the decision is made about microbiological diagnostics and antibiotic therapy (if streptococcal pharyngotonsillitis is suspected) or about only symptomatic treatment and no further diagnostics (if the clinical picture suggests viral pharyngotonsillitis) (1, 3, 5, 17, 18). There are three clinical scales evaluating the probability of streptococcal pharyngitis: according to Breese, Centor?s with McIssac modification and Welsh?s. Since Breese?s scale does not allow streptococcal infection to be ruled out in patients with low risk and is based on the number of leukocytes in the blood, the other two are much more useful in everyday clinical practice. Walsh?s scale, however, has been verified only in adults. Therefore Polish Recommendations 2010 consider Centor/McIssac?s scale to be the most useful one, since it may be used for both children and adults (1, 5). Centor/
/McIssac?s scale, the likelihood of streptococcal infection and suggested management are depicted in tables 1 and 2.
Table 1. Centor/McIssac?s scale (adapted from Hryniewicz W. et al. (1) with permission).
| Criteria | Points |
| Temperature > 38°C | 1 |
| Absence of cough | 1 |
| Swollen, tender anterior cervical nodes | 1 |
| Tonsillar swelling or exudate | 1 |
| Age 3-14 years | 1 |
| Age 15-44 years | 0 |
| 45 years or older | -1 |
Table 2. Likelihood of streptococcal infection and suggested management (adapted from Hryniewicz W. et al. (1) with permission).
| Score | Percentage of patients with confirmed S. pyogenes infection | Suggested management |
| 0 | 2-3% | No further testing or antibiotic |
| 1 | 4-6% |
| 2 | 10-12% | Culture or RADT, antibiotics only if positive results |
| 3 | 27-28% |
| 4 | 38-63% | Treat empirically with antibiotics and perform culture or RADT, cease antibiotics if negative results |
Microbiological diagnosis of streptococcal
pharyngotonsillitis
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Piśmiennictwo
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