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PubMed1988

Streptococcal pharyngitis. What's new.

Group A beta-hemolytic streptococcal pharyngitis continues to be a major problem and accounts for a large number of physician visits. The recent resurgence of acute rheumatic fever in several areas in the United States underlines the need to accurately diagnose and correctly treat streptococcal pharyngitis. Appropriate treatment with antibiotics effectively prevents rheumatic fever. Early institution of treatment also leads to prompt alleviation of symptoms. The "gold standard" for diagnosing group A streptococcal pharyngitis is the throat culture. Newer rapid diagnostic tests may be used, but the clinician must recognize that there are a substantial number of false-negative tests (low sensitivity). Therefore, patients with negative rapid tests should have standard throat cultures as well. Patients with positive rapid tests should be treated with appropriate antibiotics, as should patients with positive throat cultures. Patients with signs and symptoms that are highly suggestive of streptococcal pharyngitis can also be treated, pending throat culture results. Penicillin continues to be the drug of choice for treatment, and American Heart Association guidelines suggest the use of oral penicillin V for ten days or intramuscular benzathine penicillin G. Alternative antibiotics commonly used include erythromycin and various cephalosporins. Throat cultures need not be obtained from most patients after therapy. However, some patients may seem to be having frequent streptococcal infections or may be recognized as asymptomatic carriers. Carriers may be considered for therapy with intramuscular benzathine penicillin G plus oral rifampin.

Anti-Bacterial Agents↗

PubMed1993

Office diagnosis and management of group A streptococcal pharyngitis employing the rapid antigen detecting test. A 1-year prospective study of reliability and cost in primary care centres.

The impact of introducing the rapid antigen detecting test for the diagnosis of group A streptococcal pharyngitis in primary care centres and the direct and comprehensive cost-effectiveness of four alternative strategies for the management of group A streptococcal pharyngitis and the prevention of rheumatic fever were assessed in a 1-year prospective randomized study, carried out in children between the ages of 5 and 14 years. Data from the study showed that the test was easy to perform and reliable when introduced as a service in primary care. The strategy of using the rapid antigen detecting test and a 10-day oral penicillin course for diagnosis and treatment proved to be the safest and most cost-effective. If compliance with a 10-day course of oral penicillin is unlikely to be achieved, the strategy of introducing the test and treatment by intramuscular benzathin penicillin G proved to be the second best cost-effective alternative. In developing countries, where acute rheumatic fever is still common and the cost of the test and a 10-day course of penicillin may prove to be formidable, a strategy of treating all children with pharyngitis with intramuscular benzathin penicillin G seems to be the most cost-effective. The strategy of diagnosing group A streptococcal pharyngitis on clinical grounds proved to be the worst.

Adolescent↗

PubMed2000

General practitioners' patterns of antimicrobial drugs prescription in the therapy of acute pharyngitis.

OBJECTIVE: To analyse the patterns of antibiotic prescription in the treatment of acute pharyngitis among a group of general practitioners (GPs). DESIGN: From the records of their patients, 11 specialists in general practice have collected post hoc data on their patients and on acute pharyngitis in the period from October 1, 1994 to September 30, 1995. SETTING: 11 teaching practices in four health centres in Zagreb, Croatia. SUBJECTS: GPs grouped according to whether they had pre-school children in their care. MAIN OUTCOME MEASURES: The choice and cost of the prescribed antimicrobial drug, and the impact of the characteristics of the population in care to the prescription rate and structure. RESULTS: An antimicrobial drug was prescribed in 784 (72.1%) cases of pharyngitis. Two groups of GPs have shown significant differences in the prescription rate (p < 0.001), and in the choice of antimicrobial drugs (p < 0.001). CONCLUSION: GPs with a larger number of patients in their care suffering from chronic diseases tend to prescribe antimicrobial drugs more often in the treatment of acute pharyngitis.

Acute Disease↗

PubMed1956

The incidence and pathogenesis of myocarditis in rabbits after group A streptococcal pharyngeal infections.

Rabbits subjected to single pharyngeal infections with group A streptococci developed cardiac lesions characterized by myofiber necrosis and a non-granulocytic cellular reaction with histiocytes, lymphocytes, and Anitschkow myocytes. The histopathologic changes were demonstrable in some animals within 24 hours of inoculation, apparently were maximal 72 hours after induction of infection (at which time they were seen in the hearts of all nine rabbits studied), and thereafter healed in the course of the following 2 weeks. The extent of involvement was variable, and with healing the necrotic areas were replaced by fibrous tissue. When intradermal infections with the same organisms were produced in rabbits, cardiac lesions, indistinguishable from those observed in the pharyngeally infected group, appeared in a much smaller number of animals. The hearts of five of six rabbits sacrificed a month or more following the last of a series of streptococcal pharyngeal infections exhibited lesions characterized chiefly by fibrosis, although mononuclear cellular infiltrations were also noted. In these repetitively infected animals the presence of occasional multinucleated giant cells and a few small foci of calcification were features not encountered in the single infection group. In a second series of rabbits sacrificed 3 days after the last of three pharyngeal infections with different strains of streptococci, acute as well as more chronic changes were observed. In none of the lesions in rabbits subjected to single or multiple streptococcal infections were bacteria demonstrable, either in histologic sections or in cultures of myocardial tissue. A large number of control animals was studied concomitantly, and in only one instance was a lesion, considered comparable to those described in the streptococcal series, encountered. The implications of these findings, particularly in terms of the non-suppurative sequelae of streptococcal infections in man, are discussed.

Animals↗

PubMed1993

Direct inoculation of food as the cause of an outbreak of group A streptococcal pharyngitis.

An investigation was conducted of a food-related outbreak of group A streptococcal pharyngitis following an elementary school banquet. Of 166 surveyed banquet attendees, 71 (43%) reported outbreak-associated pharyngitis, and 21 (88%) of 24 tested attendees had evidence of group A streptococcus (GAS) in the throat. Attendees who ate macaroni and cheese were three times more likely to develop pharyngitis than those who did not (66/132 [50%] vs. 5/30 [17%], P = .002). None of the food handlers had GAS recovered by throat culture. However, the cook who prepared the macaroni and cheese had a hand wound; a wound culture grew GAS with the same T agglutination pattern and M- and/or opacity factor type as that of all available GAS strains from ill attendees. Under laboratory conditions, macaroni and cheese supported rapid growth of the outbreak-associated strain of GAS. To the authors' knowledge, this is the first documented foodborne outbreak of GAS pharyngitis in which the only apparent source of contamination was a food handler's skin lesion.

Disease Outbreaks↗

PubMed2026

Incidence of invasive group A streptococcal infections and comparison of emm types from invasive infections, pharyngitis, and throat carriage in American Indian communities in the Southwest United States.

BACKGROUND: American Indian/Alaska Native (AI/AN) communities in the US have high rates of group A streptococcal (GAS) infections. We determined the incidence of invasive infections in AI communities in the Southwest and compared emm types from invasive infections, pharyngitis, and throat carriage. METHODS: Activities conducted in the White Mountain Apache Tribal lands (WMA) and Navajo Nation (NN) included active, laboratory-based surveillance for invasive GAS infections (WMA: 2019─2024; NN: 2023─2024; all ages); surveillance for GAS pharyngitis (2023-2024; children 0─17 years); and culture for GAS from oropharyngeal carriage samples (2019 and 2022─2023; children 0─14 years). Emm types were determined by whole-genome sequencing. Annual incidence rates were calculated using Poisson regression. RESULTS: In WMA, age-standardized rates of invasive infections ranged from 80-270/100,000 persons between 2019-2024. Predominant emm types varied (n=74 isolates): 91 (59%) and 49 (32%) in 2019-2020, and 43 (40%) and 53 (30%) in 2023. In NN, rates were 40-60/100,000 persons in 2023-2024; common emm types (n=51) were 53 (28%), 101 (18%), and 12 (16%). In WMA and NN, emm types 1, 12, and 53 predominated in pharyngitis (n=190), and 1, 12, and 91 in throat carriage (n=119). CONCLUSIONS: Rates of invasive GAS infections in these communities were 3-35 times higher than the national US average (12.2/100,000 in 2024). Emm types varied over time with limited overlap in strains from throat carriage or pharyngitis isolates and those from invasive infections. Findings support continuing GAS surveillance and engaging AI/AN communities throughout vaccine development and evaluation.

Indigenous health↗

PubMed1988

Dietary factors in oral and pharyngeal cancer.

A population-based case-control study of oral and pharyngeal cancer conducted in four areas of the United States provided information on a number of risk factors, including diet. Interviews were obtained from 871 oral cancer patients and 979 controls among whites, frequency matched for age and sex. Consumption frequency of 61 food items was assessed in the questionnaire; attention was given to foods that are sources of vitamins A and C and carotene. The major finding was an inverse relationship between fruit intake and risk of oral and pharyngeal cancer; individuals in the highest quartile of intake had about half the risk of those in the lowest quartile. Vitamin C, carotene, or fiber in fruit did not appear to account completely for this relationship, since these nutrients in vegetables did not provide similar protection. This finding suggests the influence of other constituents in fruits, although it is possible that cooking vegetables may have a nutrient-diminishing effect. Dietary intake of other nutrients, such as the B vitamins, vitamin E, folate, and iron, showed no consistent relationship to risk of oral and pharyngeal cancer. Coffee or other hot beverage consumption did not increase risk; intake of nitrite-containing meats or cooking practices, such as smoking, pickling, or charcoal grilling, also did not increase risk. All analyses were adjusted for the effects of tobacco and alcohol, strong risk factors for oral and pharyngeal cancer. Dietary findings among the few subjects who did not use tobacco or alcohol were similar to those for all subjects.

Adult↗

PubMed1996

Motor control of the pharyngeal musculature and implications for the pathogenesis of obstructive sleep apnea.

Obstructive sleep apnea is a common breathing problem that results in recurrent episodes of nighttime hypoxemia, hypercapnia, bradytachycardia, and hypertension, as well as sleep disturbance and daytime hypersomnolence. The obstruction is located in the oropharynx and is caused by hypotonia of the pharyngeal dilator muscles. In this paper, the various mechanisms affecting motor output to the upper airway muscles are reviewed. In particular, the respiratory function of the pharyngeal dilator muscles, the various reflex mechanisms underlying their control, and the effects of sleep on these mechanisms are discussed. The literature relevant to the central neuronal circuits and neurotransmitters that may be involved in the state-dependent activity of the pharyngeal dilator muscles is also reviewed. In addition to an examination of these basic mechanisms, consideration is given throughout this review as to how these mechanisms may relate to the normal control of pharyngeal patency awake and asleep and how they may be involved in the pathogenesis of obstructive sleep apnea.

Carbachol↗

PubMed2004

Postural effects on pharyngeal protective reflex mechanisms.

STUDY OBJECTIVES: Pharyngeal muscle dilators are important in obstructive sleep apnea pathogenesis because the failure of protective reflexes involving these muscles yields pharyngeal collapse. Conflicting results exist in the literature regarding the responsiveness of these muscles during stable non-rapid eye movement sleep. However, variations in posture in previous studies may have influenced these findings. We hypothesized that tongue protruder muscles are maximally responsive to negative pressure pulses during supine sleep, when posterior tongue displacement yields pharyngeal occlusion. DESIGN: We studied all subjects in the supine and lateral postures during wakefulness and stable non-rapid eye movement sleep by measuring genioglossus and tensor palatini electromyograms during basal breathing and following negative pressure pulses. SETTING: Upper-airway physiology laboratory of Sleep Medicine Division, Brigham and Women's Hospital. SUBJECTS/PARTICIPANTS: 17 normal subjects. MEASUREMENTS AND RESULTS: We observed an increase in genioglossal responsiveness to negative pressure pulses in sleep as compared to wakefulness in supine subjects (3.9 percentage of maximum [%max] +/- 1.1 vs 4.4 %max +/- 1.0) but a decrease in the lateral decubitus position (4.1 %max +/- 1.0 vs 1.5 %max +/- 0.4), the interaction effect being significant. Despite this augmented reflex, collapsibility, as measured during negative pressure pulses, increased more while subjects were in the supine position as compared with the lateral decubitus position. While the interaction between wake-sleep state and position was also significant for the tensor palatini, the effect was weaker than for genioglossus, although, for tensor palatini, baseline activity was markedly reduced during non-rapid eye movement sleep as compared with wakefulness. CONCLUSION: We conclude that body posture does have an important impact on genioglossal responsiveness to negative pressure pulses during non-rapid eye movement sleep. We speculate that this mechanism works to prevent pharyngeal occlusion when the upper airway is most vulnerable to collapse eg, during supine sleep.

Adult↗

PubMed2003

The validity of diagnostic criteria for streptococcal pharyngitis in Integrated Management of Childhood Illness (IMCI) guidelines.

The WHO's Integrated Management of Childhood Illness (IMCI) programme is being implemented in Turkey with an additional section relating to throat problems for our country's adaptation. The aim of this study is to evaluate the validity of this additional part and suggest new combinations for the diagnosis of streptococcal pharyngitis to improve the guidelines. Throat swabs were obtained from 245 children between 0 and 17 years of age with signs and symptoms of upper respiratory tract infections. Considering the throat culture based diagnosis as the gold standard, the validity of the symptoms alone and in combinations were calculated. The combination in Turkey's IMCI guideline was found to be 36.9 per cent sensitive and 68.3 per cent specific. Sensitivities of combinations including at least two of the following three symptoms, namely sore throat, pharyngeal erythema, and pharyngeal exudates or sore throat, pharyngeal erythema, and fever, were 76.9 and 87.7 per cent, respectively. Specificities of the same combinations were 49.4 and 30.6 per cent. We concluded that new combinations with a higher sensitivity may be considered as a criterion for antibiotic treatment.

Adolescent↗

PubMed1987

Streptococcal pharyngitis in the 1980s.

Streptococcal pharyngitis remains a common problem in children and adolescents. However, the incidence of acute rheumatic fever is now quite low except in developing countries. Proper management of streptococcal pharyngitis has contributed significantly to the decline in ARF. Penicillin treatment has clearly altered the natural history of streptococcal infection; the acute illness is shortened, risk of spread of infection is reduced, suppurative complications are prevented and ARF is prevented. Some cases of acute glomerulonephritis may be prevented. The decline in rheumatic fever has probably contributed to a greater interest in clinical benefits of therapy. Antigen detection tests appear promising for providing a more rapid bacteriologic diagnosis of streptococcal infection, which in turn permits prompt treatment. While penicillin has been the treatment of choice for four decades, a disturbing trend of increasing numbers of clinical relapses or recurrent infections has been noted in recent years. Alternative antibiotics, such as the oral cephalosporins, may now be superior to oral penicillin in terms of lessening the risk of relapse. This advantage must be weighed against other factors including cost effectiveness. The most pressing dilemma for the clinician is management of the patient with repeated episodes of acute streptococcal pharyngitis. Certain of these problem patients may benefit from a period of penicillin prophylaxis during the seasons when streptococcal infections are most prevalent. There is now agreement that posttreatment throat cultures need not be done in the child who remains asymptomatic following therapy. However, it is incumbent on the clinician to make certain that appropriate therapy is prescribed and that compliance with oral regimens of therapy is satisfactory in the management of the patient with acute streptococcal pharyngitis.

Acute Disease↗

PubMed2002

Promoting condoms for oral sex: impact on pharyngeal gonorrhea among female brothel-based sex workers.

BACKGROUND: Low condom use for oral sex among female brothel-based sex workers in Singapore has led to a rise in pharyngeal gonorrhea. GOAL: The goal of the study was to evaluate a program promoting the use of condoms for oral sex. STUDY DESIGN: We used the time-series design to compare condom use and pharyngeal gonorrhea trends before and after program intervention in 1996 and the pretest-posttest matched control group design to determine the impact of brothel interventions on sex workers. RESULTS: Consistent oral condom use increased significantly from 42.2% in 1996 to 89.9% in 2000, with a corresponding decline in pharyngeal gonorrhea (in comparison with no significant changes before intervention). Among sex workers in brothels with interventions there was a 10.8% absolute increase in condom use, compared with an 11.7% decrease in condom use in the control group. The gonorrhea incidence rate was also significantly much lower in the intervention group than in the control group (adjusted risk ratio: 0.22; 95% CI: 0.06-0.78). CONCLUSION: The intervention increased oral condom use, with a decline in the incidence of pharyngeal gonorrhea.

Adult↗

PubMed1981

Streptococcal pharyngitis in infants: a reappraisal of its prevalence.

The prevalence of group A streptococcal pharyngitis in children under 3 years of age was determined by retrospective review of the results of throat cultures taken from children seen in a middle-class, suburban, private pediatric practice. Of 2,200 throat cultures obtained, 7% (149) were from children in this age group, and 15% (23) of these were positive for group A streptococci. All children had pharyngeal injection and the majority were symptomatic, with fever, rash, or rhinitis. Exudative pharyngitis was rare. This study suggests that pharyngeal infection with this organism in infants and young children is not uncommon, and justifies the need for throat cultures in this population.

Child, Preschool↗

PubMed2006

Treatment of streptococcal pharyngitis with once-daily compared with twice-daily amoxicillin: a noninferiority trial.

BACKGROUND: Two relatively small previous studies comparing once-daily amoxicillin with conventional therapy for group A streptococcal (GAS) pharyngitis reported similar rates of bacteriologic success for each treatment group. The purpose of this study was to further evaluate once-daily amoxicillin for GAS pharyngitis in a larger study. METHODS: In a single pediatric practice, from October through May for 2 consecutive years (2001-2003), we recruited children 3 to 18 years of age who had symptoms and signs suggestive of GAS pharyngitis. Patients with a positive rapid test for GAS were stratified by weight (<40 kg or >or=40 kg) and then randomly assigned to receive once-daily (750 mg or 1000 mg) or twice-daily (2 doses of 375 mg or 500 mg) amoxicillin for 10 days. We determined bacteriologic failure rates for GAS in the pharynx from subsequent swabs taken at 14 to 21 (visit 2) and 28 to 35 (visit 3) days after treatment initiation. We conducted a randomized, controlled, investigator-blinded, noninferiority trial to evaluate whether amoxicillin given once daily would have a bacteriologic failure rate no worse than that of amoxicillin given twice daily within a prespecified margin of 10%. GAS isolates were characterized to distinguish bacteriologic failures from new acquisitions. Adverse events were described and adherence was evaluated by review of returned daily logs and dosage bottles. RESULTS: Of 2139 potential study patients during the 2-year period, we enrolled 652 patients, 326 into each treatment group. Children in the 2 groups were comparable with respect to all demographic and clinical characteristics except that children <40 kg more often presented with rash in each treatment group. At visit 2, failure rates were 20.1% (59 of 294) for the once-daily group and 15.5% (46 of 296) for the twice-daily group (difference, 4.53%; 90% confidence interval [CI], -0.6 to 9.7). At visit 3, failure rates were 2.8% (6 of 216) for the once-daily group and 7.1% (16 of 225) for the twice-daily group (difference, -4.33; 90% CI, -7.7 to -1.0). Gastrointestinal and other adverse events occurred in the once-daily treatment group with a frequency comparable to that in the twice-daily treatment group. Presumed allergic reactions occurred in 0.9% (6 of 635). More than 95% (516 of 541) of patients complied with 10 days of therapy with no significant differences between groups. CONCLUSIONS: We conclude that amoxicillin given once daily is not inferior to amoxicillin given twice daily. Gastrointestinal and other events did not occur significantly more often in the once-daily treatment group. From the data in this large, investigator-blinded, controlled study, once-daily amoxicillin appears to be a suitable regimen for treatment of GAS pharyngitis.

Adolescent↗

PubMed2006

Evaluation of culture and antibiotic use in patients with pharyngitis.

OBJECTIVES: The objectives of this study were to evaluate practice patterns for treatment of patients with pharyngitis with regard to testing for group A beta hemolytic streptococcal (GABHS) infection, frequency of antibiotic use, and appropriate choice of antibiotics. STUDY DESIGN: The authors conducted a retrospective review of billing data for 10,482 office visits for pharyngitis. METHODS: The 2004 billing database for a tertiary institution was queried for outpatient visits for pharyngitis or tonsillitis, group A Streptococcus tests (GAST), and antibiotic prescriptions filled after the visit. Patients were separated by age group and analyzed for the proportion of patients that received a GAST and proportion prescribed an antibiotic. Antibiotic prescriptions were also analyzed to determine whether they were appropriate for treatment of GABHS. RESULTS: A total of 68.7% of all patients and 82.2% of pediatric patients were tested for GAST. A total of 47.1% of adult patients and 44.9% of pediatric patients received an antibiotic. For adult patients for whom GAST was obtained, 48.6% were prescribed an antibiotic versus 53.6% of those not tested. Streptococcus testing was a significant predictor of antibiotic use (P < .0001), whereas age was not (P = .22). A total of 82.1% of all antibiotics prescribed were recommended for treatment of GABHS. CONCLUSIONS: Most patients seen for pharyngitis were tested for GABHS, but pediatric patients were tested more frequently than adults. Patients who received a GAST were less likely to receive antibiotics. The rates experienced in our tertiary academic institution are higher than previously quoted for community practice. When antibiotics were prescribed, they were usually appropriate for the treatment of GABHS based on current recommendations.

Adolescent↗

PubMed1988

Pharyngeal diverticula: is a positive family history unusual or of consequence?

The aetiology of pharyngeal diverticula is unclear. There are only a few case reports of pharyngeal pouches occurring in families in the literature and the importance of inheritance has been relegated to 'other proposed aetiological factors' in a recent paper. We studied the incidence of a family history in all patients diagnosed as having pharyngeal pouches between 1980 and 1985 in the Leeds/Bradford area. Of 32 people questioned, 7 had died leaving no relative to provide the information. Five patients (20%) recorded a positive family history and 20 patients (80%) a negative history. This finding is of relevance to the controversy surrounding cricopharyngeal myotomy in combination with pouch excision. If these patients have a congenitally weak posterior pharyngeal wall then they may have a greater risk of recurrence without a simultaneous myotomy.

Adult↗

PubMed1996

Pharyngeal dysesthesia as an aura in temporal lobe epilepsy.

PURPOSE: Because oral, buccal, and sometimes oral-pharyngeal manifestations in epilepsy are linked to the central-temporal region, we studied 3 patients with childhood-onset partial seizures that consistently began with pharyngeal dysesthesias, described as either throat tingling or burning, to localize seizure onset. METHODS: Because of an intractable clinical course, each patient underwent invasive video-EEG monitoring, which localized the epileptogenic zone to the mesial temporal lobe. The 3 patients underwent temporal lobe resections. RESULTS: All 3 patients achieved remission of the pharyngeal auras and a 90-100% reduction in the frequency of their seizures. CONCLUSIONS: Pharyngeal dysesthesias can be the initial manifestation of complex partial seizures (CPS) of temporal lobe origin.

Adolescent↗

PubMed1996

Increased acetaldehyde production by mouthwashings from patients with oral cavity, laryngeal, or pharyngeal cancer.

Excessive ethanol consumption is associated with an increased risk of oral cavity, laryngeal, and pharyngeal cancer. Ethanol has been shown to be oxidized to acetaldehyde by microflora of the upper respiratory tract. As a highly toxic and reactive compound, acetaldehyde of microbial origin has been incriminated as a possible carcinogenic factor behind alcohol-associated malignancies of the upper respiratory tract. The aim of the present in vitro study was to compare the acetaldehyde producing capacity of mouthwashings obtained from patients with oral cavity, laryngeal, or pharyngeal cancer to that of mouthwashings from controls. The ability of mouthwashings to produce acetaldehyde from ethanol in vitro was determined by incubating them in closed vials containing various concentrations of ethanol (0-44 mM) at 37 degrees C for 1 hr. Acetaldehyde formed during the incubation was then analyzed by head space gas chromatography. Acetaldehyde production by mouthwashings increased with raising ethanol concentration in both groups. Acetaldehyde production by mouthwashings from patients with oral cavity, laryngeal, or pharyngeal cancer was significantly (p < 0.01) higher than that of the controls. Increased acetaldehyde formation from ethanol in the upper respiratory tract could thus contribute to the pathogenesis of alcohol-associated oral cavity, laryngeal, and pharyngeal cancers.

Acetaldehyde↗