• Infl ammation of the tonsils & pharynx • Etiologies include bacterial (group A β-hemolytic streptococcus, Haemophilus infl uenzae, Fusobacterium sp,
etc) & viral (infl uenza, adenovirus, coronavirus, rhinovirus, etc) pathogens • Sore throat is the most common presenting symptom in older children
2 EVALUATION FOR COMPLICATIONS
• Patients w/ sore throat may have deep neck infections including epiglottitis, peritonsillar or retropharyngeal abscess
• Examine for signs of upper airway obstructionSigns & Symptoms of Sore � roat w/ Complications• Trismus• Inability to swallow liquids• Increased salivation or drooling• Peritonsillar edema• Deviation of uvula• Asymmetry & forward displacement of the soft palateSigns of Upper Airway Obstruction• Stridor• Air hunger• Respiratory distress• Toxic appearance• CyanosisManagement of Complications• All abscesses should be drained • Tonsillectomy if patient has a history of recurrent tonsillitis• Acute tonsillectomy without prior incision
3 EVALUATION FOR GABHS INFECTION
• Identify & treat GABHS infection as soon as possible after diagnosis to decrease risk of complications like acute rheumatic fever (ARF), glomerulonephritis, pediatric autoimmune neuropsychiatric disorders associated w/ streptococcal infection (PANDAS) syndrome, & decrease period of contagiousness
• GABHS is the most common bacterial pathogen of ATP & warrants antibiotic treatment • GABHS infection should be suspected on clinical & epidemiological grounds & supported by laboratory tests • Viral pathogens are more frequent than bacteria, accounting for about 70-90% of cases in children, & almost
100% in children <3 years of ageSigns & Symptoms Suggestive of GABHS Infection • Sore throat/tonsillar swelling/exudates• Swollen anterior cervical nodes• Fever >38ºC (low-grade fever <38ºC in children <3 years old)• Lack of cough, conjunctivitis, rhinorrhea, hoarseness • Symptoms in a patient aged 5-15 yearsSigns & Symptoms Suggestive of a Viral Etiology• Rhinorrhea• Cough• Hoarseness• Conjunctivitis• Diarrhea• Oropharyngeal ulceration• Muscle & joint pain
• Tests not needed for patients whose features do not suggest GABHS infection• For patients 3-15 years of age, perform diagnostic tests when GABHS cannot be excluded Rapid Antigen Detection Test (RADT)• Advantage of speed (within minutes versus 48 hours for culture) & specifi city (≥95%) for GABHS• Children w/ throat pain w/ ≥2 of the following are recommended to undergo RADT:
- Absence of cough- Presence of tonsillar exudates/swelling- History of fever- Age >15 years- Positive for swelling & tenderness of the anterior cervical lymph nodes
• Confi rmation w/ culture is not necessary after a negative RADT result� roat Swab Culture• Highly sensitive (90-95% sensitivity) but not done routinely because of delay in results (18-24 hours)
- Recommended for those w/ history of contact w/ symptomatic persons w/ GABHS pharyngitis, recurrent GABHS infection & symptomatic patients at high risk for rheumatic fever
• � roat swabs from both tonsils & posterior pharyngeal wall• Optimal time for collection is at onset of symptoms & before antibiotics are startedCentor Criteria• Used to assess the susceptibility of patients to GABHS infection based on the patient’s age & symptoms
- Results may assist in the decision to start antibiotic treatment• Uses a points system utilizing the following signs/symptoms:
- Fever (>38oC) (1)- Absence of cough (1)- Tender anterior cervical node (1)- Tonsillar exudate/swelling (1)- Age 3-14 years (1)- Age 15-44 years (0)- Age >44 years (-1)
• Modifi ed total risk based on total ATP score: Total score Risk of GABHS
≥4 51-53%3 28-35%2 11-17%1 5-10%
≤0 1-2.5%FeverPAIN Score• May be used to assess the need to start antibiotic treatment as well as the severity of throat pain • High results may indicate streptococcal infection; results should be correlated w/ Centor criteria score
5 RESPONSE TO THERAPY
• Clinical response is usually evident within 24-48 hours• Persistence beyond 48 hours may indicate alternative causes or development of suppurative complications
which warrants reassessment
A SUPPORTIVE MANAGEMENTGeneral Measures• Adequate fl uid intake• Warm saline gargle (¼ teaspoon of salt per 8 oz glass of water)• Elimination of close contact w/ family members or visitors if patient has been confi rmed to have GABHS • Remain at home until 24 hours of antibiotic therapy has been receivedAlternative � erapy • � ere are not enough studies to support use of acupunture & herbal treatments for tonsillopharyngitis
Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.
B PHARMACOLOGICAL THERAPY - NON-GABHS INFECTIONSymptomatic Treatment• Symptomatic treatment is important in the management of children w/ sore throatSimple Analgesics/Antipyretics• Paracetamol is the drug of choice for analgesia in sore throat• Aspirin is not recommended due to the risk of Reye’s syndromeNonsteroidal Anti-infl ammatory Drugs (NSAIDs)• Ibuprofen is a safe & eff ective alternative for analgesia & antipyrexia• Diclofenac may also be used for against pain caused by ATP • As NSAIDs are associated w/ signifi cant risk of GI bleeding, their routine use is not recommended� roat Lozenges/Gargle/Spray • May be helpful especially in those w/ signifi cant throat pain or discomfort
Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.
C PHARMACOLOGICAL THERAPY - GABHS INFECTIONSymptomatic Treatment• Important in the management of children w/ sore throat• Same as for non-GABHS infectionAntimicrobial � erapy• Treatment started only for documented GABHS infection• Due to practical constraints, antibiotics may be started empirically if:
- GABHS is clinically suspected- Patient is toxic-looking- Follow-up is not possible
• Empiric treatment of GABHS is discouraged due to poor diagnostic accuracy even w/ elaborate clinical scoring systems
• A RADT or throat swab should be taken before starting empiric antibiotics • If antibiotics are started empirically, & culture results are negative, the antibiotic should be discontinued• Appropriate antibiotics prevent ARF, prevent suppurative complications, decrease infectivity & shorten clinical
coursePenicillin• Drug of choice• Proven effi cacy, narrow spectrum, safety & low cost• Full 10-day course of treatment for oral medications• IM penicillin may be advisable if poor compliance is a concernAmoxicillin• Better tolerated than Penicillin • 2nd line to Penicillin in pediatric patients due to taste preferenceMacrolides• Eg Azithromycin, Clarithromycin, Erythromycin, Roxithromycin• May be used for patients w/ Penicillin allergy• Local resistance patterns vary geographically & should be included in the consideration for an alternative
antibiotic in Penicillin-allergic patients • Azithromycin or Cephalexin may be used for Erythromycin-intolerant patientsCephalosporins• Eg Cefaclor, Cefadroxil, Cefdinir, Cefi xime, Cefpodoxime, Cephalexin • Alternative to Amoxicillin for the eradication of streptococcal infection especially in recurrent cases• Studies show that a 5-day treatment w/ a cephalosporin is superior to a 10-day course w/ PenicillinClindamycin• May be used for those who are both Penicillin-allergic & Erythromycin-intolerant• Reported resistance of GABHS isolates to Clindamycin are generally low & thus may still be considered a
D SURGERYTreatment Goal• For recurrent tonsillopharyngitis, surgery aims for reduction in occurrence of sore throat & improved general
health w/ tonsillectomyIndications for TonsillectomyRecurrent Tonsillitis• Sore throat due to infl ammation of tonsils• ≥7 episodes of tonsillitis over a 12-month period or ≥5 episodes/year in the past 2 years or ≥3 episodes/year
in the past 3 years w/ documentation for each episode of sore throat & ≥1 of the following:- Temperature >38.3°C (101°F)- Cervical adenopathy- Tonsillar exudate- Positive test for GABHS infection
• Symptoms interfere w/ patient’s normal daily functionPeritonsillar Abscess or Quinsy• All abscesses should be drained• Tonsillectomy if without response to appropriate antibiotics &/or incision & drainageContraindications to Tonsillectomy• Velopharyngeal insuffi ciency, hematologic factors (anemia, etc) & presence of local infection
Not all products are available or approved for above use in all countries.Specifi c prescribing information may be found in the latest MIMS.
Special Instructions• Use w/ caution in patients w/ renal or hepatic
dysfunction
CEPHALOSPORINS
Drug Dosage Remarks
First GenerationCefadroxil 30 mg/kg/day PO 24 hrly or divided 12 hrly Adverse Reactions
• Hypersensitivity reactions (urticaria, pruritus, rash, severe reactions eg anaphylaxis can occur); GI eff ects (diarrhea, N/V, rarelyantibiotic-associated diarrhea/colitis); Other eff ects (Candidal infections)
• High doses may be associated w/ CNS eff ects (encephalopathy, convulsions);Rarely hematologic eff ects; Hepatic & renal eff ects have occurred
Special Instructions• May be taken w/ food to
decrease gastric distress• Use w/ caution in patients
allergic to Penicillin, there may be 10% chance of cross sensitivity
• Use w/ caution in patients w/ renal impairment
Cefalexin(Cephalexin)
25-50 mg/kg/day PO divided 6 hrly
Second GenerationCefaclor >1 mth: 20-40 mg/kg/day PO divided 8 hrly
Max dose: 1 g/day<1 yr: 62.5 mg PO 8 hrly1-5 yr: 125 mg PO 8 hrly>5 yr: 250 mg PO 8 hrly
Cefprozil 7.5 mg/kg PO 12 hrlyMax dose: 500 mg/day
Cefuroxime <40 kg: 10 mg/kg PO 12 hrly or 125 mg PO 12 hrly≥40 kg: 250 mg PO 12 hrly
� ird GenerationCefditoren pivoxil ≥12 yr: 200 mg PO 12 hrly x 10 daysCefdinir 14 mg/kg/day PO 24 hrly or divided 12 hrly
Max dose: 600 mg/dayCefi xime >6 mth-2 yr: 8 mg/kg PO 24 hrly or 25-50 mg
PO 12 hrly or 50-100 mg PO 24 hrlyMax dose: 100 mg/day3-6 yr: 50-100 mg PO 12 hrly or 100-200 mg PO 24 hrly7-12 yr: 100-150 mg PO 12 hrly or 200-300 mg PO 24 hrly >12 yr: 200 mg PO 12 hrly or 400 mg PO 24 hrly
Cefpodoxime 8-10 mg/kg/day PO in 2 divided doses Max dose: 200 mg/day
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
Erythromycin 30-50 mg/kg/day PO divided 12 hrly Adverse Reactions• GI eff ects (N/V, abdominal discomfort,
diarrhea & other GI disturbances, antibiotic-associated diarrhea/colitis); Other eff ect (Candidal infections)
• Hypersensitivity reactions are uncommon (urticaria, pruritus, rash, rarely anaphylaxis); Rarely cardiotoxicity, hepatotoxicity; Dose-related tinnitus/hearing loss have occurred w/ some macrolides
• Azithromycin & Clarithromycin tend to cause less GI disturbances than Erythromycin
Special Instructions• May take w/ food to decrease gastric
distress• Use w/ caution in patients w/ hepatic
dysfunction
Midecamycin 30 mg/kg/day PO divided 6-8 hrly Roxithromycin 5-8 mg/kg/day PO divided 12 hrlySpiramycin 50-75 mg/kg/day PO divided 8-12 hrly x
5 daysAdvanced MacrolidesAzithromycin ≥6 mth/<15 kg: 10 mg/kg PO 24 hrly x
3 days or10 mg/kg PO 24 hrly x 1 day followed by 5 mg/kg PO 24 hrly x 4 daysMax dose: 500 mg/day>45 kg: 500 mg PO 24 hrly x 3 days
Clarithromycin 15 mg/kg/day PO divided 12 hrly or 250 mg PO 12 hrly x 10 days
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs)
Drug Dosage Remarks
Diclofenac ≥14 yr: 75-100 mg PO divided in 2-3 dosesMax dose: 150 mg/day
Adverse Reactions• GI eff ects (GI ulceration/bleeding/perforation, N/V, diarrhea,
Special Instructions• Contraindicated in women in the last trimester of pregnancy,
patients w/ active gastric or intestinal ulcer/bleeding/perforation, severe hepatic, renal or cardiac failure, hypersensitivity to Aspirin or any other NSAID including those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by Aspirin or any other NSAID
Ibuprofen 3-6 mth: 5 mg/kg PO 8 hrly>6 mth-1 yr: 50 mg PO 8 hrly1-2 yr: 50 mg PO 6-8 hrly3-7 yr: 100 mg PO 6-8 hrly8-12 yr: 200 mg PO 6-8 hrly
Adverse Reactions• GI eff ects (GI discomfort, nausea, diarrhea, including risk of
GI bleeding & ulcers) • Hematological eff ect (inhibition of platelet aggregation)Special Instructions• To be administered w/ or after food, milk or antiulcer drugs to
prevent GI eff ects • Avoid in patients w/ peptic ulceration, hypersensitivity to
Aspirin or any other NSAID including those in whom attacks of asthma, angioedema, urticaria or rhinitis have been precipitated by Aspirin or any other NSAID
• Use w/ caution in patients w/ hypertension, renal, hepatic or cardiac dysfunction
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
1� ese agents are found in various throat & mouth preparations throughout diff erent countries. � ey are available as lozenges, paints, mouthwashes, mouth gel & oral soln. Please see the latest MIMS for specifi c formulations.
ORAL CARE1
Drug IndicationsBenzoic acid Preservative; has antibacterial propertiesBorax Has weak bacteriostatic propertiesEucalyptol Counter irritantMenthol Used to relieve symptoms of sinusitis, etcMuramidase (Lysozyme) Mucopolysaccharidase normally present in salivaSodium benzoate Preservative; has antibacterial properties� ymol Antiseptic
OTHER DRUGS ACTING ON THE RESPIRATORY SYSTEMDrug Dosage Remarks
Lyophilized bacterial lysates ofH infl uenzae, D pneumoniae, K pneumoniae & ozaenae, S aureus, S pyogenes & viridans, N catarrhalis
6 mth-12 yr:Preventive treatment: 3.5 mg PO 24 hrly x 10 days/mth for 3 mthAcute treatment: 3.5 mg PO 24 hrly x 10 days
Adverse Reactions• GI eff ects (N/V, abdominal pain); Other eff ects (headache,
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.
PREPARATIONS FOR ORAL ULCERATION & INFLAMMATION1
Drug Indications
Aminoacridine (Acridine) AntisepticAmylmetacresol AntisepticAmylocaine Local anestheticAzulene Local anti-infl ammatory eff ectBacitracin Local antibioticBenzalkonium chloride AntisepticBenzethonium chloride AntisepticBenzocaine Local anestheticBenzoxonium chloride AntisepticBenzydamine Local anti-infl ammatory eff ectBiclotymol Antiseptic
1� ese agents are found in various throat & mouth preparations throughout diff erent countries. � ey are available as lozenges, paints, mouthwashes, mouth gel & oral soln. Please see the latest MIMS for specifi c formulations.
All dosage recommendations are for children w/ normal renal & hepatic function unless otherwise stated.Not all products are available or approved for above use in all countries.
Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.
Specifi c prescribing information may be found in the latest MIMS.Please see the end of this section for reference list.
PREPARATIONS FOR ORAL ULCERATION & INFLAMMATION (CONT’D)1
Drug Indications
Carbenoxolone Mucosal protectantCetalkonium chloride AntisepticCetrimide AntisepticCetrimonium bromide AntisepticCetylpyridinium chloride AntisepticChlorhexidine Antiseptic & disinfectantChlorobutanol Antiseptic & disinfectantChloroxylenol AntisepticCholine salicylate Rubefacient used as analgesicDequalinium AntisepticDibucaine (Cinchocaine) Local anestheticDichlorobenzyl alcohol AntisepticDomiphen bromide AntisepticEnoxolone Treatment of non-infective infl ammatory disorders of the mouth, throatGlycyrrhizin Local anti-infl ammatory eff ectGramicidin Local antibacterial agentHexetidine Bacteriocidal agentHexylresorcinol AntisepticHydroxybenzoate Antiseptic & preservativeLidocaine (Lignocaine) Local anestheticNeomycin Local antibioticPhenol Antiseptic & disinfectantPolicresulen AntisepticPovidone-iodine Antiseptic & disinfectantSalicylic acid Local analgesic, anti-infl ammatorySodium salicylate Local analgesic, anti-infl ammatoryTyrothricin Local treatment of infections
1� ese agents are found in various throat & mouth preparations throughout diff erent countries. � ey are available as lozenges, paints, mouthwashes, mouth gel & oral soln. Please see the latest MIMS for specifi c formulations.
