CLINICAL PHARMACY

PHARYNGITIS AND
TONSILLITIS
Submitted to:
Dr. Muhammad Fawad Rasool

Submitted By:
M Tayyeb Mehmood 64-E-14
Shahid hussain 67-E-14
Usman Munir 78-E-14
M Arsalan Chishti 85-E-14
Qirtas Tauheed 100-E-14
 Pharyngitis and tonsillitis are infections in the
throat that cause inflammation.These are acute
infection of the oropharynx or nasopharynx that results
in 10% of all outpatient visits and 50 % patients
antibiotic use. Although viral causes are most common,
group A β-hemolytic Streptococcus (GABHS), or
Streptococcus pyogenes, is the primary bacterial
cause.Pharyngitis due to GABHS is commonly known as
“sore throat”.
Pharyngitis Tonsillitis

Primarily
Affected

Throat Tonsils
Normal Infected
Pharyngitis
Tonsillitis
Epidemiology
 Acute pharyngitis accounts for approx 2 million
people at a cost of upto $539 million for children
alone.

 Although viral causes are more common, GABHS

(Group A Beta-Hemolytic Streptococci.) is
primary bacterial cause.
Supportive and nonsupportive
complications:
Acute
rhumatic
fever Acute
Necrotizing
glomerulo-
fasciitis
nephritis
Retro-
pharangal
Cervical abscess Reactive
lymph-
adenitis arthritis
Peritonsillar
abscess
Cont....
Population at high risk:
Age:
 Children 5-15 years and parents of school age childrens.
 In child younger than 3 years Pharyngitis is rarely
caused by GABHS.
Season:
 Highest in winter and early spring.
 Incubation period 2-5 days.
Transmission:
 Direct contact (usually from hands) with droplets of
saliva or nasal secretions, and worsen in institutions,
schools, families and crowded areas.
Etiology
 Viruses

 Rhinovirus (20%)
 Coronavirus(5%)
 Adenovirus(5%)
 Herpes simplex virus(4% )
 Influenza virus (2%)
 Parainfluenza virus (2%)
 Epstein-barr virus (1%)
 Bacteria

GABHS
(Group A Beta-Hemolytic Streptococci)

Most
common

Pediatrics Adults
(15-30%) (5-15%)
Less common Bacteria:

 Group C & G streptococcus

 Corynebacterium diphtheriae
 Neisseria gonorrhoeae
 Mycoplasma pneumoniae
 Arcanobacterium haemolyticum
 Yersinia enterocolitica
 Chlamydia pneumoniae
Pathophysiology:
 Mechanism of action:
Exact mechanism is unknown.

 Carriers of the organism may have an alteration

in host immunity (e.g, a breach in the
pharyngeal mucosa) and the bacteria of the
oropharynx may migrate to cause an infection.
Pathogenic Factors
 Streptococci are members of the normal flora. Pathogenic
factors of group A streptococci include:

Erythrogenic Produce rashes by damaging

Toxins cell membranes of blood
Cytolytic capillaries

Hemolysins (α) and (β) Lysis of RBCs

Strepto Increase bacterial

Plasminogen plasmin Infection
kinase
 Fibrinogen

Proteases Degrade Fibrinogen

Fibronectin

Hyaluronic
Inhibits phagocytosis
acid

M Protein Facilitate bacterial

attachment
 Clinical
Presentation
Throat swab
& culture
Test

RADT
(Rapid Antigen Detection Test)
Throat swab Test:

Throat
RADT
Culture
 Throat Culture Test:
It is diagnostic test that evaluates for the presence of a
bacterial or fungal infection in the throat

 Sample is collect by throat swabbing or throat washout.

 placing the sample into a special cup (culture) that
allows infections to grow.
Growth No Growth

Positive Negative

Infection No
confirmed Infection
RADT(Rapid Antigen Detection Test):

Rapid strep test (RST)

Diagnosis of bacterial pharyngitis caused by group A

streptococci (GAS)

 Sample is collect by throat swabbing or throat washout.

 Sample is then exposed to a reagent containing
antibodies that will bind specifically to a gas antigen.
 A positive result is signified by a certain visible reaction.
 Discussion

 Microbiologic testing is recommended for

symptomatic patient untill they have
symptoms suggestive of viral etiology or are
younger than 3 year of age.

 Only those with positive test for GABHS

require antibiotic treatment.
TREATMENT
Desired outcome:
 To improve clinical signs and symptoms
minimize ADRs.
 Prevent transmission to close contact.
 Prevent acute rheumatic fever.
 Supportive complications:
Peritonsillar abscess
Cervical lymphadenitis
Mastoiditis.
General Approach to
treatment:
 Once the GABHS pharyngitis is diagnosed, the
clinician must decide approprite supportive care,
when to initiate antibiotic therapy, the
appropriate antibiotic, and the duration of
therapy.

 Antibiotic overuse should be avoided.

 Empirical therapy is not recommended.

 Supportive care:
 Supportive care must be given to all patients.

 Pharmacologic supportive care interventions include:

Antipyretics
Analgesics
Non prescription lozenges
Sprays containing menthol and anesthetics for relief of pain.

 Analgesics (acetaminophen and NSAIDs) are highly

recommended Because pain is primary reason for visiting a
physician.
 Corticosteroids are not recommended due to high risk of ADRs.
 Pharmacologic therapy:

 Amoxicillin is more preferable for children because

suspension is more palatable than penicillin.
Dose:
One daily extended release formulation of amoxicillin
has been approved for GABHS pharyngitisin adults and children
older than 12 year age.
 Rheumatic fever following GABHS pharyngitis
treated with with Procaine penicillin, later
replace with banzathine penicillin.

 IM benzathine penicillin can be given (although it

is painful) if oral route is not available due to any
reason.

 IM banzathin penicillin G every 4 weeks is

recommended for secondary prevention

 Newer Macrolids, (azithromycin and

clarithromycin) are preffered over erythromycin.
 Not Recommended
Tetracycline GABHS is resistant

Sulfonamides and
Poor eradication
trimethoprim-
sulfamethoxazole rates for GABHS

Poor activity of older agents

Flouroquinoline and newer agents are
expensive
 Course of therapy:

1. Long course Therapy:

 Duration of therapy for GABHS pharyngitis is 10 days, except
for benzathine penicillin and azythromycin, to maximize
bacterial eradication.
2. Short course therapy:
 A Chochrane review, published in 2012, examined short
course therapy and concluded that 3-6 days of oral antibiotic
and comparable efficacy to oral penicillin for 10 days.
Cont....
 Impact of antibiotic is to decreasing of duration
of signs and symptoms after 24 hours of
antibiotic therapy.
 GABHS carriers do not need antimicrobial therapy
due to very low risk of spreading of disease or
developing supportive or non supportive
complications.
 But When acute GABHS occur in carrier, then
treatment course of antibiotic is recommended.
Penicillin Alternatives
 Amoxicillin- Penicillin/
Clindamycin
clavulanate rifampin

For recurrent episodes of pharyngitis

Azithromycin Clarithromycin Clindamycin

First
generation
If the reaction is
cephalosporin non ige-mediated.
Sulfadiazine
Penicillin-
allergic

Penicillin and
Macrolide
sulfadiazine-
or azalide
allergic
 Personalized pharmacotherapy:

 Factors that should be considered when personalizing

therapy for a patient include allergy status, prior
antibiotic use, and adherence.

 Those with the history of antibiotic use for acne may be

at higher risk for resistant strains of GABHS.

 Short-course antibiotics or penicillin G banzathine may

be considered in patient with history of nonadherence.
Evaluation of therapeutic
outcomes:
 Most pharyngitis are self limiting however; Generally fever
and other symptoms resolve within 3-4 days of onset
without antibiotic however symptoms will improve 0.5-2
days earlier with antibiotics.
 Follow up testing is not necessary for asymtomati contacts
but throat cultures 2-7 days after completion of antibiotics
are warranted for patients who remain symptomatic.
 May ALLAH Bless you With
Good health & prosperity in All your LIFE