Pharyngitis: Difference between revisions
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==Background==
==Background==
[[File:Gray1014.png|thumb|Anatomy of the posterior pharynx.]]
*1-2% of all ED visits<ref name="hildreth">Hildreth AF, Takhar S, Clark MA, Hatten B. Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department. Emerg Med Pract. 2015;17(9):1-16.</ref>
*Viral is most common cause (~70% in children, ~90% in adults)<ref name="mahp">Michigan Quality Improvement Consortium. Acute Pharyngitis in Children (3 years and older), Adolescents and Adults Guideline. 2025.</ref>
**Exudates do not mean bacterial — most common cause of exudative pharyngitis is still viral
**Common viral etiologies: [[Rhinovirus]], [[Coronavirus]], [[Adenovirus]], [[Influenza]], [[Coxsackievirus]], [[EBV]]
*Bacterial causes:
**''[[Streptococcal pharyngitis|Group A Streptococcus]]'' (GAS): most important bacterial cause
**Group C and G ''Streptococcus'': can cause pharyngitis but do not cause [[acute rheumatic fever]]
**''[[Fusobacterium necrophorum]]'': increasingly recognized cause in adolescents/young adults (may cause up to 10-20% of pharyngitis in this age group); can lead to [[Lemierre's syndrome]]<ref name="centor2009">Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med. 2009;151(11):812-815.</ref>
**''[[Neisseria gonorrhoeae]]'': consider in sexually active patients with pharyngitis and relevant exposure history
**''[[Corynebacterium diphtheriae]]'': rare in developed countries; consider in unvaccinated or recent travelers
===[[Streptococcal pharyngitis]]===
===[[Streptococcal pharyngitis]]===
*Accounts for only 15-30% of pharyngitis
*Accounts for 5-15% of pharyngitis in adults and 15-30% in children<ref name="idsa2025">Barshak MB, Dien Bard J, Linder J, et al. 2025 Clinical Practice Guideline Update by the Infectious Diseases Society of America: Diagnosis of Group A Streptococcal Pharyngitis. Clin Infect Dis. 2025.</ref>
*Peak in 5-15yr old
*Peak incidence in ages 5-15 years
*Rare in <2yr of age
*Rare in children <3 years of age (typically presents as "streptococcosis" with rhinitis/low-grade fever rather than classic pharyngitis)
*Seasonal: winter and early spring
*Treatment can be delayed for up to 9 days from symptom onset and still prevent [[acute rheumatic fever]]<ref name="idsa2012">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):e86-102.</ref>


==Clinical Features==
==Clinical Features==
[[File:Pos strep.jpg|thumb|culture positive strep pharyngitis with typical tonsillar exudate]]
[[File:Pharyngitis.jpg|thumb|Generalized erythema of the pharynx, consistent with pharyngitis.]]
[[File:Pos strep.jpg|thumb|Culture positive strep pharyngitis with typical tonsillar exudate]]
 
===General===
*[[Sore throat]]
*[[Sore throat]]
*Painful swallowing
*Painful swallowing (odynophagia)
*[[Fever]]
*[[Fever]]
*[[Nausea and vomiting]]
*[[Nausea and vomiting]]
*Tonsillar exudate
*Tonsillar exudate
*Palatal petechiae
*Anterior cervical [[lymphadenopathy]]
*Palatal [[petechiae]]
 
===Features Favoring Bacterial (GAS) Etiology===
*Sudden onset sore throat
*Fever ≥38.3°C (101°F)
*Tonsillar exudate
*Tender anterior cervical lymphadenopathy
*Absence of cough, rhinorrhea, conjunctivitis, hoarseness, or oral ulcers<ref name="idsa2012"/>
 
===Features Favoring Viral Etiology===
*[[Cough]]
*[[Rhinorrhea]]
*hoarseness
*Oral ulcers
*[[Conjunctivitis]]
*[[Diarrhea]]
*Characteristic viral exanthems (e.g., [[hand-foot-and-mouth disease]])
*Viral symptoms reduce likelihood but do not exclude GAS (test positivity still ~23-28% with viral symptoms present)<ref name="maeda2020">Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847-852.</ref>
 
===Classic Clues for Specific Diagnoses===
*Post-treatment with [[amoxicillin]]/[[ampicillin]] → diffuse pruritic maculopapular [[rash]] = classic for [[EBV]] pharyngitis ([[infectious mononucleosis]])
*Unilateral sore throat, "hot potato" voice, trismus, uvular deviation = [[peritonsillar abscess]]
*Sore throat with high fever progressing to unilateral neck swelling/pain and sepsis in a young adult = consider [[Lemierre's syndrome]]<ref name="kuppalli">Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre's syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012;12(10):808-815.</ref>
*Gray pharyngeal membrane in unvaccinated patient = [[Diphtheria]]
*Vesicular/ulcerative lesions on posterior pharynx = [[Herpangina]] or [[HSV]]
*Pharyngitis with splenomegaly, posterior cervical lymphadenopathy, fatigue = [[infectious mononucleosis]]
*Pharyngitis with diffuse lymphadenopathy, [[rash]], oral ulcers = consider acute HIV
 
{{Modified Centor Criteria}}
 
===ED Red Flags===
*[[Stridor]], drooling, tripoding → evaluate for [[epiglottitis]], [[retropharyngeal abscess]], or other airway emergency
*Inability to tolerate secretions or worsening [[dysphagia]]
*Toxic appearance / signs of [[sepsis]]
*Unilateral neck swelling with persistent high fevers → consider [[Lemierre's syndrome]] or deep neck space infection
*Floor of mouth swelling → [[Ludwig's angina]]
*Trismus → [[peritonsillar abscess]], deep neck space infection
 
==Complications==
===Suppurative===
*[[Peritonsillar abscess]]
*[[Retropharyngeal abscess]]
*Cervical [[lymphadenitis]]
*[[Mastoiditis]]
*[[Lemierre's syndrome]] (septic thrombophlebitis of the internal jugular vein)<ref name="kuppalli"/>
 
===Nonsuppurative===
*[[Acute rheumatic fever]] (prevented by antibiotics if started within 9 days)
*[[Post-streptococcal glomerulonephritis]] (NOT prevented by antibiotics)
*[[Scarlet fever]]
*[[Toxic shock syndrome]]
*[[Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS)]]


==Differential Diagnosis==
==Differential Diagnosis==
Line 20: Line 89:


==Evaluation==
==Evaluation==
{{Modified Centor Criteria}}
{{RADT algorithm}}
 
===Key Evaluation Principles===
*Do not test patients with clear viral features ([[cough]], [[rhinorrhea]], hoarseness, oral ulcers, [[conjunctivitis]]) — treat supportively<ref name="idsa2012"/><ref name="idsa2025"/>
*Do not routinely test children <3 years of age (both GAS and [[acute rheumatic fever]] are rare), unless risk factors (e.g., sibling with GAS)<ref name="idsa2012"/>
*The 2025 IDSA guideline update recommends using a standardized clinical scoring system (e.g., Modified Centor/McIsaac) to identify low-risk patients who do not need testing<ref name="idsa2025"/>
*For those meeting testing criteria: use Rapid Antigen Detection Test (RADT)
**RADT sensitivity 70-90%, specificity >95%
**In children/adolescents: a negative RADT should be backed up with a throat culture (higher false-negative rate)<ref name="idsa2012"/>
**In adults: backup throat culture generally not required (lower incidence and lower risk of [[acute rheumatic fever]])<ref name="idsa2012"/>
*Centor/McIsaac score of 0-1: do not test, treat symptomatically
*Centor/McIsaac score of ≥2: test with RADT (± backup culture in children)
*Do not test asymptomatic contacts routinely<ref name="idsa2012"/>
*Do not perform test of cure after treatment unless history of [[acute rheumatic fever]] or recurrent GAS complications<ref name="idsa2012"/>
 
===Additional Testing to Consider (When Clinically Indicated)===
*Monospot / heterophile antibody for suspected [[infectious mononucleosis]] (note: 25% false-negative in first 10 days of illness)<ref name="beyea">Beyea JA, et al. Pharyngitis: Approach to diagnosis and treatment. Can Fam Physician. 2020;66(4):251-257.</ref>
*[[Gonorrhea]] NAAT for suspected [[gonococcal pharyngitis]]
*CT neck with contrast if concern for deep neck space infection, [[peritonsillar abscess]], or [[Lemierre's syndrome]]
*[[HIV]] testing if risk factors and clinical features suggest acute retroviral syndrome


==Management==
==Management==
===Symptomatic Treatment===
*Analgesics/antipyretics are the foundation of treatment for ALL pharyngitis (viral and bacterial)
**[[Ibuprofen]] 400-600mg PO q6h PRN (adults); 10 mg/kg PO q6h PRN (pediatric)
**[[Acetaminophen]] 1000mg PO q6h PRN (adults); 15 mg/kg PO q4-6h PRN (pediatric)
**Ibuprofen may be slightly more effective for throat pain than acetaminophen<ref name="mahp"/>
**Avoid [[aspirin]] in children ([[Reye syndrome]])
*Topical therapies:
**Salt water gargle
**Viscous [[lidocaine]] (adults) — use with caution due to aspiration risk
**Consider "magic mouthwash" ([[diphenhydramine]]/[[lidocaine]]/antacid mixture)
*Hydration: encourage oral fluids, soft diet; assess ability to tolerate PO before discharge
===[[Antibiotics]]===
===[[Antibiotics]]===
{{Streptococcal Pharyngitis Antibiotics}}
{{Streptococcal Pharyngitis Antibiotics}}
*Treatment is indicated for laboratory-confirmed GAS pharyngitis (RADT or culture positive)<ref name="idsa2012"/>
*'''Do not''' treat empirically based on clinical features alone in most cases<ref name="idsa2025"/>
*Goal: prevent [[acute rheumatic fever]], reduce suppurative complications, improve symptoms, decrease transmission
*Key point: antibiotics shorten symptom duration by approximately 1-2 days when started early<ref name="spinks">Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev. 2021;12:CD000023.</ref>


===[[Steroids]]===
===[[Steroids]]===
*Single dose of [[dexamethasone]] shortens duration of pain<ref>Hayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012 Oct 17;10:CD008268. PMID: 23076943.</ref>
*In adults consider single dose of [[dexamethasone]] 0.6mg/kg PO (Max = 10mg)<ref>[[EBQ:TOAST Trial]]</ref>
**[[Dexamethasone]] 0.6mg/kg PO - maximum of 10mg
**Reduces pain severity and time to onset of pain relief (~4-12 hours faster resolution)
*In children consider single dose of [[dexamethasone]] 0.6mg/kg PO (Max = 10mg)<ref name="olympia">Olympia RP. The Effectiveness of Oral Dexamethasone in the Treatment of Moderate to Severe Pharyngitis in Children and Young Adults. Acad Emerg Med. 2003;10(5). doi:10.1197/aemj.10.5.434-a</ref>
*Note: The 2012 IDSA guideline did not recommend routine adjunctive corticosteroids; however, emergency medicine literature supports their use for pain relief<ref name="idsa2012"/>


==Disposition==
==Disposition==
*Discharge
===Discharge (Majority of Patients)===
*Discharge home with symptomatic treatment ± antibiotics
*Patient can return to work/school after ≥24 hours of antibiotic therapy and clinical improvement (for confirmed GAS)<ref name="cdc">CDC. Clinical Guidance for Group A Streptococcal Pharyngitis. Centers for Disease Control and Prevention. Updated November 2025. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html</ref>
*Return precautions:
**Unable to tolerate oral fluids
**Worsening sore throat or new difficulty swallowing despite treatment
**Difficulty breathing or changes in voice
**Persistent or worsening fever after 48 hours of antibiotics
**New unilateral neck swelling or stiffness
 
===Consider Admission===
*Inability to tolerate oral fluids (especially in children) → IV hydration
*Concern for airway compromise
*Sepsis or toxic appearance
*Suspected deep neck space infection, [[Lemierre's syndrome]], or other suppurative complication requiring IV antibiotics and imaging
 
==ED Pearls==
*Most sore throats are viral — focus on symptom management and avoid unnecessary antibiotics
*[[Centor Criteria]] help identify who does NOT need testing (score 0-1), not who has strep
*Exudate ≠ bacterial; viral pharyngitis frequently causes exudates
*Treatment for GAS can be safely delayed up to 9 days and still prevent [[acute rheumatic fever]] — you do not need to prescribe empiric antibiotics from the ED without testing
*Think about ''[[Fusobacterium necrophorum]]'' and [[Lemierre's syndrome]] in any adolescent or young adult with a prolonged, severe, or worsening sore throat, especially with lateral neck pain/swelling or signs of sepsis<ref name="centor2009"/>
*''[[Post-streptococcal glomerulonephritis]]'' is NOT prevented by antibiotic treatment (unlike [[acute rheumatic fever]])
*[[Infectious mononucleosis]] + [[amoxicillin]]/[[ampicillin]] = maculopapular rash (present in up to 70-100% of cases)
*Consider acute HIV in any patient with a mononucleosis-like illness and negative Monospot
*Always assess for ability to tolerate PO fluids before discharging pharyngitis patients, particularly young children


==Complications==
== Calculators ==
*[[Acute rheumatic fever]]
{{Centor_Calculator}}
*[[Scarlet fever]]
*[[Toxic shock syndrome]]
*[[Post-streptococcal glomerular nephritis]]
*[[Pediatric autoimmune neuropsychiatric disorder associated with group A streptococci (PANDAS)]]
*[[Peritonsillar abscess]]
*Cervical lymphadenitis
*[[Mastoiditis]]


==See Also==
==See Also==
*[[Sore Throat]]
*[[Sore Throat]]
*EBQ:TOAST Trial
*[[Streptococcal pharyngitis]]
*[[Peritonsillar abscess]]
*[[Lemierre's syndrome]]
*[[Infectious mononucleosis]]
*[[Retropharyngeal abscess]]
*[[Epiglottitis]]
*[[EBQ:TOAST Trial]]


==References==
==References==
<references/>
{{reflist|2}}
 
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:ENT]]
[[Category:ENT]]
[[Category:ID]]
[[Category:ID]]

Latest revision as of 09:32, 22 March 2026

Background

Anatomy of the posterior pharynx.

Streptococcal pharyngitis

  • Accounts for 5-15% of pharyngitis in adults and 15-30% in children[4]
  • Peak incidence in ages 5-15 years
  • Rare in children <3 years of age (typically presents as "streptococcosis" with rhinitis/low-grade fever rather than classic pharyngitis)
  • Seasonal: winter and early spring
  • Treatment can be delayed for up to 9 days from symptom onset and still prevent acute rheumatic fever[5]

Clinical Features

Generalized erythema of the pharynx, consistent with pharyngitis.
Culture positive strep pharyngitis with typical tonsillar exudate

General

Features Favoring Bacterial (GAS) Etiology

  • Sudden onset sore throat
  • Fever ≥38.3°C (101°F)
  • Tonsillar exudate
  • Tender anterior cervical lymphadenopathy
  • Absence of cough, rhinorrhea, conjunctivitis, hoarseness, or oral ulcers[5]

Features Favoring Viral Etiology

Classic Clues for Specific Diagnoses

Modified Centor Criteria[8]

One point is given for each of the criteria:[8]

  1. Absence of a cough
  2. Swollen and tender cervical lymph nodes
  3. Temperature >38.0 °C (100.4 °F)
  4. Tonsillar exudate or swelling
  5. Age less than 15^
    • Subtract a point if age >44
Modified Centor score
Points Probability of Streptococcal pharyngitis
1 or fewer <10%
2 11–17%
3 28–35%
4 or 5 52%

ED Red Flags

Complications

Suppurative

Nonsuppurative

Differential Diagnosis

Acute Sore Throat

Bacterial infections


Viral infections


Noninfectious


Other

Oral rashes and lesions

Evaluation

Rapid Antigen Detection Test Algorithm for Acute Pharyngitis[10]

Category Testing and Treatment
Clinical features strongly suggesting viral etiology (eg. cough, rhinorrhea, hoarseness, oral ulcers)
  • None
<3 years old
  • None because immature immune system not mature enough to develop anti-streptolysin O (ASO) antibodies and acute rheumatic fever[11].
    • Unless they have a special risk factor (e.g. older sibling with GAS infection)
CENTOR = 1
  • None
None of the above with CENTOR ≥2
  • Send rapid antigen detection test
    • Positive = treat
    • Negative
      • Children and adolescents
        • Send back up throat culture (treat later, if positive)
      • Adults
        • None (no need for back up throat culture)

Diagnostic testing or empiric treatment of asymptomatic household contacts of patients with acute streptococcal pharyngitis is not routinely recommended

Key Evaluation Principles

  • Do not test patients with clear viral features (cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis) — treat supportively[5][4]
  • Do not routinely test children <3 years of age (both GAS and acute rheumatic fever are rare), unless risk factors (e.g., sibling with GAS)[5]
  • The 2025 IDSA guideline update recommends using a standardized clinical scoring system (e.g., Modified Centor/McIsaac) to identify low-risk patients who do not need testing[4]
  • For those meeting testing criteria: use Rapid Antigen Detection Test (RADT)
    • RADT sensitivity 70-90%, specificity >95%
    • In children/adolescents: a negative RADT should be backed up with a throat culture (higher false-negative rate)[5]
    • In adults: backup throat culture generally not required (lower incidence and lower risk of acute rheumatic fever)[5]
  • Centor/McIsaac score of 0-1: do not test, treat symptomatically
  • Centor/McIsaac score of ≥2: test with RADT (± backup culture in children)
  • Do not test asymptomatic contacts routinely[5]
  • Do not perform test of cure after treatment unless history of acute rheumatic fever or recurrent GAS complications[5]

Additional Testing to Consider (When Clinically Indicated)

Management

Symptomatic Treatment

  • Analgesics/antipyretics are the foundation of treatment for ALL pharyngitis (viral and bacterial)
    • Ibuprofen 400-600mg PO q6h PRN (adults); 10 mg/kg PO q6h PRN (pediatric)
    • Acetaminophen 1000mg PO q6h PRN (adults); 15 mg/kg PO q4-6h PRN (pediatric)
    • Ibuprofen may be slightly more effective for throat pain than acetaminophen[2]
    • Avoid aspirin in children (Reye syndrome)
  • Topical therapies:
  • Hydration: encourage oral fluids, soft diet; assess ability to tolerate PO before discharge

Antibiotics

Treatment can be delayed for up to 9 days and still prevent major sequelae

Penicillin Options:

Penicillin allergic (mild):

Penicillin allergic (anaphylaxis):[13]

  • Clindamycin 7 mg/kg/dose TID (maximum = 300 mg/dose) x 10 days[19]
  • Azithromycin 12 mg/kg PO once (maximum = 500 mg), then 6 mg/kg (max=250 mg) once daily for the next 4 days[20]
  • Clarithromycin 7.5 mg/kg/dose PO BID (maximum = 250 mg/dose) x 10 days[21]


Pediatric Dosing:

  • Amoxicillin 50mg/kg PO once daily x 10 days (max 1000mg)
  • Penicillin V <27kg: 250mg PO BID-TID x 10 days; >27kg: 500mg PO BID-TID x 10 days
  • Penicillin G Benzathine <27kg: 600,000 units IM x 1; >27kg: 1.2 million units IM x 1
  • PCN allergy (mild): Cephalexin 20mg/kg PO BID x 10 days (max 500mg/dose)
  • PCN allergy (mild): Cefadroxil 30mg/kg PO daily x 10 days (max 1g)
  • PCN allergy (severe): Azithromycin 12mg/kg PO day 1 (max 500mg), then 6mg/kg daily x 4 days (max 250mg)
  • PCN allergy (severe): Clindamycin 7mg/kg/dose PO TID x 10 days (max 300mg/dose)
  • PCN allergy (severe): Clarithromycin 7.5mg/kg PO BID x 10 days (max 250mg/dose)
  • Treatment is indicated for laboratory-confirmed GAS pharyngitis (RADT or culture positive)[5]
  • Do not treat empirically based on clinical features alone in most cases[4]
  • Goal: prevent acute rheumatic fever, reduce suppurative complications, improve symptoms, decrease transmission
  • Key point: antibiotics shorten symptom duration by approximately 1-2 days when started early[24]

Steroids

  • In adults consider single dose of dexamethasone 0.6mg/kg PO (Max = 10mg)[25]
    • Reduces pain severity and time to onset of pain relief (~4-12 hours faster resolution)
  • In children consider single dose of dexamethasone 0.6mg/kg PO (Max = 10mg)[26]
  • Note: The 2012 IDSA guideline did not recommend routine adjunctive corticosteroids; however, emergency medicine literature supports their use for pain relief[5]

Disposition

Discharge (Majority of Patients)

  • Discharge home with symptomatic treatment ± antibiotics
  • Patient can return to work/school after ≥24 hours of antibiotic therapy and clinical improvement (for confirmed GAS)[27]
  • Return precautions:
    • Unable to tolerate oral fluids
    • Worsening sore throat or new difficulty swallowing despite treatment
    • Difficulty breathing or changes in voice
    • Persistent or worsening fever after 48 hours of antibiotics
    • New unilateral neck swelling or stiffness

Consider Admission

  • Inability to tolerate oral fluids (especially in children) → IV hydration
  • Concern for airway compromise
  • Sepsis or toxic appearance
  • Suspected deep neck space infection, Lemierre's syndrome, or other suppurative complication requiring IV antibiotics and imaging

ED Pearls

  • Most sore throats are viral — focus on symptom management and avoid unnecessary antibiotics
  • Centor Criteria help identify who does NOT need testing (score 0-1), not who has strep
  • Exudate ≠ bacterial; viral pharyngitis frequently causes exudates
  • Treatment for GAS can be safely delayed up to 9 days and still prevent acute rheumatic fever — you do not need to prescribe empiric antibiotics from the ED without testing
  • Think about Fusobacterium necrophorum and Lemierre's syndrome in any adolescent or young adult with a prolonged, severe, or worsening sore throat, especially with lateral neck pain/swelling or signs of sepsis[3]
  • Post-streptococcal glomerulonephritis is NOT prevented by antibiotic treatment (unlike acute rheumatic fever)
  • Infectious mononucleosis + amoxicillin/ampicillin = maculopapular rash (present in up to 70-100% of cases)
  • Consider acute HIV in any patient with a mononucleosis-like illness and negative Monospot
  • Always assess for ability to tolerate PO fluids before discharging pharyngitis patients, particularly young children

Calculators

Centor/McIsaac Score

Modified Centor (McIsaac) Score
Criteria No (0) Yes (+1)
Tonsillar exudates or swelling 0 1
Tender/swollen anterior cervical lymph nodes 0 1
Temperature >38°C (100.4°F) 0 1
Absence of cough 0 1
Age modifier (McIsaac modification)
Age 3–14 years 0 1 (+1)
Age 15–44 years (0 points — default)
Age ≥45 years 0 -1 (−1)
Modified Centor Score 0   / 5
Interpretation & Management
≤0 ~1–2.5% strep probability — No testing or antibiotics needed.
1 ~5–10% strep probability — No testing or antibiotics needed (optional rapid strep if high clinical suspicion).
2–3 ~11–35% strep probability — Rapid strep testing recommended; treat if positive.
4–5 ~51–53% strep probability — Consider empiric antibiotics or rapid strep test.
References
  • Centor RM et al. The diagnosis of strep throat in adults. Med Decis Making. 1981;1:239-246. PMID 6763125.
  • McIsaac WJ et al. A clinical score to reduce unnecessary antibiotic use. CMAJ. 1998;158:75-83. PMID 9475915.

See Also

References

  1. ↑ Hildreth AF, Takhar S, Clark MA, Hatten B. Evidence-Based Evaluation And Management Of Patients With Pharyngitis In The Emergency Department. Emerg Med Pract. 2015;17(9):1-16.
  2. ↑ 2.0 2.1 Michigan Quality Improvement Consortium. Acute Pharyngitis in Children (3 years and older), Adolescents and Adults Guideline. 2025.
  3. ↑ 3.0 3.1 Centor RM. Expand the pharyngitis paradigm for adolescents and young adults. Ann Intern Med. 2009;151(11):812-815.
  4. ↑ 4.0 4.1 4.2 4.3 Barshak MB, Dien Bard J, Linder J, et al. 2025 Clinical Practice Guideline Update by the Infectious Diseases Society of America: Diagnosis of Group A Streptococcal Pharyngitis. Clin Infect Dis. 2025.
  5. ↑ 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 5.9 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):e86-102.
  6. ↑ Fine AM, Nizet V, Mandl KD. Large-scale validation of the Centor and McIsaac scores to predict group A streptococcal pharyngitis. Arch Intern Med. 2012;172(11):847-852.
  7. ↑ 7.0 7.1 Kuppalli K, Livorsi D, Talati NJ, Osborn M. Lemierre's syndrome due to Fusobacterium necrophorum. Lancet Infect Dis. 2012;12(10):808-815.
  8. ↑ 8.0 8.1 Choby BA (March 2009). "Diagnosis and treatment of streptococcal pharyngitis". Am Fam Physician 79 (5): 383–90. PMID 19275067.
  9. ↑ Melio, Frantz, and Laurel Berge. “Upper Respiratory Tract Infection.” In Rosen’s Emergency Medicine., 8th ed. Vol. 1, n.d.
  10. ↑ Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82
  11. ↑ David Cisewski An Understated Myth? Strep Throat & Rheumatic Fever
  12. ↑ Beyea JA, et al. Pharyngitis: Approach to diagnosis and treatment. Can Fam Physician. 2020;66(4):251-257.
  13. ↑ 13.0 13.1 13.2 Shulman, et al. Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America. Clinical Infectious Diseases 2012;55(10):1279–82
  14. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  15. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  16. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  17. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  18. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  19. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  20. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  21. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  22. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  23. ↑ CDC Website, accessed 2026-28-01. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
  24. ↑ Spinks A, Glasziou PP, Del Mar CB. Antibiotics for treatment of sore throat in children and adults. Cochrane Database Syst Rev. 2021;12:CD000023.
  25. ↑ EBQ:TOAST Trial
  26. ↑ Olympia RP. The Effectiveness of Oral Dexamethasone in the Treatment of Moderate to Severe Pharyngitis in Children and Young Adults. Acad Emerg Med. 2003;10(5). doi:10.1197/aemj.10.5.434-a
  27. ↑ CDC. Clinical Guidance for Group A Streptococcal Pharyngitis. Centers for Disease Control and Prevention. Updated November 2025. https://www.cdc.gov/group-a-strep/hcp/clinical-guidance/strep-throat.html
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