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Acute Pharyngitis in the College Health Setting Pharyngitis accounts for 2% of visits to a doctor in the US and is due to a viral infection in ~80% of those instances. There is a wide range of viral culprits (rhino, adeno, coxackie, influenza, parainfluenza, herpes, and Epstein Barr (mono)). Each of these viral infections can cause a sore throat with or without other cold/flu symptoms. Treatment for sore throats of a viral origin is designed to decrease the symptoms while your body’s immune system eliminates the virus. These same strategies also improve symptoms of bacterial pharyngitis. Additionally antibiotic therapy is often included for the treatment of bacteria. The remaining document addresses the current clinical decision making philosophy of the CDC and the providers at the University Health Center. Bacterial Pharyngitis­Group A Beta Hemolytic Strep (GABHS); CDC Guidance • While significantly more common in children, only 5‐15% of adult cases of acute pharyngitis are caused by GABHS.
• It is estimated that 3,000 to 4,000 patients with GABHS must be treated for every 1 case of acute rheumatic fever prevented. • Antibiotic therapy of GABHS hastens resolution by 1‐2 days if initiated within 2‐3 days of symptom onset. Diagnosis and Treatment • Lab testing is not indicated in all patients with pharyngitis. For GABS, all adults should be screened for the following: •
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History of fever Lack of cough Tonsillar exudates Tender anterior cervical nodes Patients with none or only one of these findings are unlikely to have GABHS. Any one of the following three strategies is appropriate for patients with two or more of the above findings: o Rapid streptococcal antigen test (RAT) for patients with 2 or more criteria, with antibiotic therapy restricted to those with positive test results. o Rapid streptococcal antigen testing of patients with 2 or 3 criteria, with antibiotic therapy restricted to patients with all 4 findings and those with positive test results. o Empiric antibiotic therapy for patients with 3 or 4 criteria; no diagnostic testing. • Penicillin is recommended for initial treatment of GABHS. Cephalexin is an alternative. • Erythromycin is recommended for penicillin‐allergic patients. • Penicillin‐resistant GABHS have not been reported in the United States. Other Information: Bacterial Pharyngitis, Including Non­GABHS; UHC Perspectives • Individuals in the college setting often develop pharyngitis caused by Non GABHS. Some of these bacteria are anaerobes •
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(Fusobacterium Necrophorum as one example) that do not grow on a standard throat culture. A review of 15,769 cultures over 5 years at UHC revealed 33% to have grown a potential bacterial pathogen. Of those cultures: ƒ 65% were Group C Strep ƒ 17% were Group A Strep (GABHS) ƒ 11% were Group G Strep ƒ 2 % were Arcanobacterium Hemolyticum ƒ <1% were Nisseria Gonorrhea ƒ ~3% were Other or unidentified UHC doctors believe treatment of pharyngitis in the college environment must include consideration of Non GABHS bacteria disease due to its impact on academic performance as well as the high communicability associated with respiratory infections on a high population density residential campus. Symptoms of NonGABHS bacterial infections are similar to GABHS, but may include many features of a nonspecific upper respiratory infection such as cough and nasal congestion. Diagnosis and Treatment • While rapid strep testing is a mainstay of GABHS diagnosis, it does not screen for other bacteria. • The test to detect the majority of non‐GABHS is a throat culture. This is the preferred test at UHC. • The decision to treat with antibiotics is sometimes based solely on the identified or suspected cause. GABHS is always treated with antibiotics, even if symptoms are mild. •
However, Non GABHS bacteria are sometimes treated due to the severity of symptoms, the presence of complications or our desire to decrease communicability to other students. •
There is controversy regarding the best practices for evaluating and treating pharyngitis in the college population. Topic: General Respiratory Illness and Influenza Symptom Management
Below are general guidelines to help you manage your respiratory symptoms. In general, combination products (Tylenol
Cold & Sinus, Dayquil, etc) are not as effective as taking the individual components because of differences in dosing.
Also, generics are MUCH less expensive. All items listed are available in the UHC Pharmacy.
… Get more than the usual amount of rest. If you have fever or are taking medicine to reduce fever, you should not
exercise until fever is gone and you feel better. In general, limit extracurricular activity until you are well. This
should shorten the healing process.
… Drink plenty of fluids (~2-3 liters/day). This thins mucous, helps your immune system work and lessens fever.
Humidify your room by running a cool mist vaporizer or humidifier, particularly at night. Keep the machine
clean and replace filters regularly. Placing a pan of water by the bedside and steamy showers can also help.
… Antibiotics are not typically helpful, but if prescribed complete the course as directed until gone. Take all other
prescribed medications as directed. If you areprescribed an inhaler use it with a spacer to maximize
effectiveness.
… Warm saltwater (1/2 tsp salt in 1 cup warm water) gargles every 2-3 hours to soothe your throat. This will
provide temporary relief and help to thin out excess mucus. Lozenges will also help to soothe your sore throat.
… Nasal saline rinses thin mucous, decrease congestion, reduce mucous production and decrease postnasal
drainage. In general, it helps to promote a healthy environment in the sinuses and reduce your risk for
developing a sinus infection. In the event that an infection does develop, it helps to reduce the symptoms. Nasal
saline rinses are best achieved with the use of a neti pot, which can be purchased at low cost in the UHC
pharmacy. Spray bottles, commercial products such as Ocean Mist and simply “snuffing” saline from your
cupped hand may also be helpful and are also available in the UHC pharmacy.
… Elevate the head of your bed 15-20 degrees to help promote sinus drainage and lessen sinus pressure.
… For fever and/or pain: Acetaminophen (Tylenol) regular strength (325 mg)-2 tabs every 4 hours OR Extra
Strength Acetaminophen, 2 tablets up to 4 times a day. May be taken alone or in combination with ONE of the
following: Ibuprofen (Advil, Motrin) 200 mg- 4 tablets every 8 hours with food and full glass of water OR
Naproxen (Aleve) 220 mg- 2 tablets every 12 hours with food and full glass of water. Ibuprofen and Naproxen
have anti-inflammatory effects as well as help to control pain and fever, but may cause stomach irritation.
… For nasal congestion/stuffiness Pseudoephedrine XR (Sudafed XR) 120 mg (requires signature with pharmacist) 1 capsule every 12 hours. Try not to take after 7 pm as this medicine can sometimes make it difficult to get to
sleep. Phenylephrine HCL (10 mg), 1-2 tablets taken three times a day as needed, is a decongestant that is both
effective and less likely to cause heart palpitations or disturb your sleep than pseudoephedrine.
… For severe nasal congestion/stuffiness and for immediate relief, use Oxymetazoline HCl (Afrin) nasal spray. Use
one spray in each nostril twice daily for no more than 3 days OR one spray in each nostril at bedtime for no more
than 6 days. Using this medicine longer or more often than recommended can cause rebound nasal stuffiness.
… For thickened mucus/cough: Guafenesin/Dextromethorphan products (Robitussin DM, Mucinex DM) are good
cough suppressants and can be taken along with one of the decongestants above. Mucinex is a tablet form of
guafenesin and helps thin out mucus. Mucinex-D is helpful if you need a decongestant instead of a cough
suppressant.