Acute Pharyngitis/Acute Tonsillopharyngitis in Children: IAP Guidelines

Acute pharyngitis/acute tonsillopharyngitis is inflammation of the pharynx.

Acute Tonsillitis/Acute Pharyngitis/Acute Tonsillopharyngitis Patients with acute sore throat with/without dysphagia are classified under one of these diagnoses. Recurrent Acute Tonsillitis It is defined as repeated episodes of acute tonsillitis with asymptomatic periods in between the episodes. Carrier State It is defined by a positive pharyngeal culture of group A beta-hemolytic Streptococcus Pyogenes (GABHS), without any acute symptoms or evidence of an antistreptococcal immunologic response. Recurrent Streptococcal Tonsillitis When an individual has seven cultures proven episodes in 1 year, or five infections in 2 consecutive years, or three infections each year for 3 years consecutively.

The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Acute pharyngitis/acute tonsillopharyngitis. The lead author for these guidelines on Acute pharyngitis/acute tonsillopharyngitis is Dr Suresh Babu along with co-author Dr Sonia Bhatt and Dr Jijo Joseph John. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.

Following are the major recommendations of guidelines:

Causative Agents:

Viruses constitute majority of causative agent (70–95%). Group A beta-hemolytic Streptococcus is most common pathogen among bacteria. Group A Streptococcal Pharyngitis Common in children aged 5–11 years. Nearly 11–15% children aged ≥5 years act as asymptomatic carriers of group A streptococcal (GAS). Mostly present during winter and spring season.

Clinical Features:

• Sudden onset of a sore throat

• Discomfort and pain while swallowing

• Fever

Examination:

Erythema, edema, exudates, or an enanthem (ulcers and vesicles) along with lymphadenitis. A child with clinical signs of acute upper airway obstruction should be assessed for:

• Hydration status

• Fever

• Oral/pharyngeal ulcers (coxsackie virus)

• Tonsillar exudates

• Tender anterior cervical lymphadenopathy

• Hepatosplenomegaly [Epstein–Barr virus (EBV)]

• Scarlet-fever type rash-blanching, sandpaper-like rash, usually more prominent in skin creases, flushed face/cheeks with perioral pallor (GAS).

Red Flags:

Unwell/toxic appearance

Respiratory distress

• Stridor

• Trismus

• Drooling

• "Hot potato" voice (muffled voice associated with pharyngeal/peritonsillar pathology) Torticollis

• Neck stiffness/fullness. In the acutely unwell looking child consider alternative diagnosis and/or complications of GAS pharyngitis.

Complications:

The complications of GABHS pharyngitis include:

• Local suppurative complications: Parapharyngeal abscess, peritonsillar and retropharyngeal abscess, and sepsis.

• Nonsuppurative illnesses: Acute rheumatic fever, acute post-streptococcal glomerulonephritis, post-streptococcal reactive arthritis and possible pediatric autoimmune neuropsychiatric disorders associated with S. pyogenes (PANDAS) or childhood acute neuropsychiatric symptoms (CANS).

Diagnosis:

Diagnosis is mostly clinical.

Patient's history, clinical symptoms, and laboratory values all should be taken into consideration to distinguish between viral and bacterial origin (Table 1).

TABLE 1: Distinguish between viral and bacterial origin.
Group A streptococcal infection	Viral infection
Sudden onset of sore throat, presentation in winter or early spring	Conjunctivitis and viral exanthem
Age 5–15 years, history of exposure to streptococcal pharyngitis	Coryza
Fever and headache	Cough
Palatal petechiae and anterior cervical adenitis	Diarrhea
Patchy tonsillopharyngeal exudates	Hoarseness
Tonsillopharyngeal inflammation	Discrete ulcerative stomatitis

Group A beta-hemolytic Streptococcus pyogenes pharyngitis is confirmed using a positive rapid antigen detection test (RADT).

Rapid Antigen Detection Test:

Point of care test, high specificity (98.4%), sensitivity (89.7%), and diagnostic accuracy (96.4%), if RADT positive then throat swab culture is not necessary. If RADT is negative and a strong clinical suspicion of GAS pharyngitis, throat swab culture is indicated. Antistreptococcal antibody titers are not recommended routinely.

Diagnostic testing is not recommended if clinical features strongly suggest a viral etiology. Routinely performed blood tests and blood cultures are not indicated. Modified Centor or McIsaac score should be taken into account to consider ordering a rapid test or throat swab (Table 2).

TABLE 2: McIsaac score (modified Centor score).
Symptom	Score
Body temperature (in the history) > 38°C	1
No cough	1
Cervical lymph node swelling	1
Tonsillar swelling or exudation	1
Age (years)
3–14	1
15–44	0
≥45	−1

If score 0 and 1: Do not test for strep and do not treat

Score 2: Treat, if rapid strep test is positive

Score 3: Two options, treat if rapid strep test is positive or treat empirically

Score 4: Treat empirically

Treatment Regimens for Group A Streptococcal Infection:

TABLE 3: Treatment regimens for group A streptococcal (GAS) infection.
Drug	Dose/dosage	Duration
Patients without penicillin allergy
Penicillin V, oral	Children: 250 mg twice or thrice daily Adolescents and adults: 250 mg four times daily or 500 mg twice daily	10 days
Amoxicillin, oral	50 mg/kg daily in two to three divided dose (maximum = 1,000 mg) Alternative: 25 mg/kg twice daily (maximum = 500 mg)	10 days
Penicillin G benzathine, intramuscular	<27 kg: 600,000 U ≥27 kg: 1,200,000 U	Single dose
Patients with penicillin allergy
Cephalexin, oral*	20 mg/kg/dose twice daily (maximum = 500 mg/dose)	10 days
Cefadroxil, oral*	30 mg/kg once daily (maximum = 1 g)	10 days
Clindamycin, oral	7 mg/kg/dose thrice daily (maximum = 300 mg/dose)	10 days
Azithromycin oral†	12 mg/kg once daily (maximum = 500 mg)	5 days
Clarithromycin oral†	7.5 mg/kg/dose twice daily (maximum = 250 mg/dose)	10 days

Avoid in individuals with immediate hypersensitivity to penicillin.

† Resistance of group A Streptococcus to these agents is well-known and varies geographically and temporally

Adjunctive Therapy:

Analgesic or antipyretic (e.g., acetaminophen and nonsteroidal anti-inflammatory drugs) can be considered to treat moderate-to-severe symptoms or control a high fever.

Aspirin and adjunctive corticosteroids are not recommended.

Surgical Management:

Tonsillectomy is indicated for the individuals who have experienced the following:

More than six episodes of streptococcal pharyngitis (confirmed by positive culture) in 1 year. Five episodes of streptococcal pharyngitis in 2 consecutive years.

Three or more infections of the tonsils and/or adenoids per year for 3 years in a row despite adequate medical therapy.

Chronic or recurrent tonsillitis associated with the streptococcal carrier state that has not responded to beta-lactamase–resistant antibiotics.

Tips to Reduce Antibiotic Usage:

Use history, clinical symptoms, modified Centor score, and RADT to distinguish between viral and bacterial illness.

Patient with recurrent pharyngitis and laboratory evidence of GABHS may be chronic carriers and can have repeated viral infections hence antibiotics are not recommended in such cases. Effective communication regarding antibiotic resistance, specific symptomatic treatment, and a plan for follow-up, if symptoms worsen.

Centor RM, Witherspoon JM, Dalton HP, Brody CE, Link K. The diagnosis of strep throat in adults in the emergency room. Med Decis Making. 1981;1(3):239-46.

McIsaac WJ, Kellner JD, Aufricht P, Vanjaka A, Low DE. Empirical validation of guidelines for the management of pharyngitis in children and adults. JAMA. 2004;291:1587-95.

Shulman ST, Bisno AL, Clegg HW, et al. Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis. 2012;55(10):e91.

Windfuhr JP, Toepfner N, Steffen G, Waldfahrer F, Berner R. Clinical practice guideline: tonsillitis I. Diagnostics and nonsurgical management. Eur Arch Otorhinolaryngol. 2016; 273(4): 973-87. Published online 2016 Jan 11.

The guidelines can be accessed on the official site of IAP :https ://iapindia.org/standard-treatment-guidelines/