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International Journal of Pharmaceutical and Clinical Research 2015; 7(4): 226-230
ISSN- 0975 1556
Review Article

Aetiology and the use of Antibiotics in the Case of

Acute Pharyngitis: A Review
Kannan I1*, Beulah Edwin1, Vincent Prasanna2, Hemlata Katiyar VM2, Elango Dhanapal3
1

Department of Microbiology, Tagore Medical College and Hospital, Rathinamangalam, Chennai -600 127, India
2
Department of ENT, Tagore Medical College and Hospital, Rathinamangalam, Chennai -600 127, India
Available Online: 01st May, 2015

ABSTRACT
Acute pharyngitis in one of the most common illness reported in high rate in an outpatient setup. The acute pharyngitis is
caused due to infection by virus or bacteria. It is no clinical evidence that the bacterial illness and viral illness differ in
their severity and duration. Hence the clinicians are put in difficulty in the selection of treatment modality especially the
administration of antibiotics. However many research have proved that the adult pharyngitis is mainly due to virus. This
review gives the picture of the aetiology and current treatment scenario of the acute pharyngitis.
Keywords: Acute pharyngitis, virus, bacteria, treatment, antibiotics
INTRODUCTION
Acute pharyngitis in one of the most common illness
reported in high rate in an outpatient setup1. The common
symptoms include fever, sore throat and pain on
swallowing. It can cause extreme distress of the body and
can affect the routine activities of the patient. The illness
is of great concern to the clinicians as it can easily spread
to others if patient is present in close quarters. Even today
the management of acute pharyngitis remains challenging
to the clinicians because of its varied aetiology2. Further
the signs and symptom of the disease varies from patient
to patient and thus makes the clinician difficult to
ascertain proper aetiology of the illness. Even as the
clinical diagnosis fails in many cases, the laboratory
diagnosis of the disease also many times not reliable and
may be misleading. The acute pharyngitis is the
inflammation of soft tissues of the throat and can arise in
many upper respiratory tract infections. Thus the
symptoms can be presented in various degrees and thus
cannot help in clinical diagnosis. Thus acute pharyngitis
still remains as a challenge to the clinicians3.
AETIOLOGY
The acute pharyngitis is caused due to infection by virus
or bacteria4. It is no clinical evidence that the bacterial
illness and viral illness differ in their severity and
duration5.
Viral pharyngitis
The viruses are considered to play a major role in the
pathogenesis of pharyngitis6. It was found that viral
pharyngitis account for around 70% of all pharyngitis,
with bacterial causing only 20% to 40% of pharyngitis7.
The Table 1 gives the possible viruses that are involved in
the acute pharyngitis1.

*Author for Correspondence

Those respiratory viruses, such as adenovirus, rhinovirus,

respiratory syncytial virus, influenza virus and
parainfluenza virus are the main cause of acute
pharyngitis. The role of coxsakeivirus, herpesimplex
virus and echoviruses in acute pharyngitis is not ruled
out. The Epstein Barr virus is also involved in acute
pharyngitis, however is often accompanied with other
clinical features such as generalized lymphadenopathy
and splenomegaly that are characteristic of infectious
mononucleosis. Certain viruses that cause systemic
infections like rubella virus, measles and other viruses are
also associated with acute pharyngitis. Eventhough viral
acute pharyngitis is common in adults, many studies have
revealed the role of viruses, especially adenovirus and
Respiratory syncicial virus in acute childhood
pharyngitis8-10.
Some viruses produces characteristic clinical symptom
along with the pharyngitis. Adenoviruses can produce
pharyngoconjunctival fever or an influenza-like
syndrome known as the acute respiratory disease of
military recruits11. Coxsackieviruses are the most frequent
causes of handfoot- and-mouth disease and herpangina12.
Many studies have revealed that the primary human
herpesvirus 1 infection as a cause of pharyngitis13,14.
Human herpesvirus 2 can occasionally cause a similar
illness as a consequence of oralgenital sexual contact15
Bacterial pharyngitis
Many studies have revealed that Group A streptococcus is
by far the most common bacterial cause of acute
pharyngitis, accounting for approximately 15 to 30
percent of cases in children and 5 to 10 percent of cases
in adults16,17. Apart from Group A streptococcus (GAS),
some other bacteria are also have been demonstrated to
be the aetiological agent of pharyngitis. Next to GAS, it

Kannan et al. / Aetiology and the use of Antibiotics in the Case

Table 1: Viruses that cause acute pharyngitis

Virus
Symptoms/Disorders
Rhinovirus
Common cold
Coronavirus
Common cold
Adenovirus
Pharyngoconjunctival fever and
acute respiratory disease.
Herpes simplex virus Gingivostomatitis
types 1 and 2
Parainfluenza virus
Cold and croup
Coxsakievirus A
Herpangina and hand foot
and mouth disease
Epstein Barr virus
Infectious mononucleosis
Cytomegalovirus
Cytomegalovirus
mononucleosis
HIV
Primary HIV infection
Influenza A and B Influenza
viruses
has been shown the Mycoplasma pneumoniae and
Chlamydia pneumoniae can also be involved in acute
pharyngitis18. However, it has not been proved whether
these bacteria are co-pathogens or the primary
aetiological agents19,20. In another study, apart from these
bacteria, they have also found that Legionella
pneumophila also can be the causative agent of
pharyngitis21. Another important bacterium that has been
implicated in the causation of pharyngitis is
Fusobacterium necrophorum22. It occurs in patients aged
15 to 30 years. F. necrophorum can cause a severe
complication, the Lemierre syndrome23. This bacterium
has now been emerged as an important bacterium in
adolescent pharyngitis24. It is considered to be as common
as GAS in this age group25.
In an interesting finding, the group C streptococcus has
been found as the causative agent in acute pharyngitis has
been frequently isolated from throat culture.
Streptococcus equi subsp. equisimilis and S. anginosus
are the two group C streptococci that have been isolate
from pharyngitis26. However, its role in the causation of
pharyngitis is questionable27,28. Certain studies have
proved that it can cause pharyngitis29-32.
Arcanobacterium haemolyticum is another bacterium
which is rarely diagnosed to cause acute pharyngitis and
tonsillitis in adolescents and young adults. The symptoms
of infection caused by this organism closely mimic those
of acute streptococcal pharyngitis, including a
scarlatiniform rash in many patients33,34. Normally the
colonisation of the pharynx with Neisseria gonorrhoeae
is asymptomatic, however it can occasionally cause
pharyngitis35.
TREATMENT
The multiple aetiology of acute pharyngitis makes it
difficult for the physician to decide and initiate
appropriate treatment for the patient. Treatment for acute
pharyngitis nowadays more relies on patient satisfaction
rather than the aetiology of the disease36. However it is
important for the physician to decide to initiate
antibacterial therapy as in many cases the disease may be
of viral aetiology. The physician should prescribe

Table 2a: Determination of patients total sore throat

score by assigning points to the following criteria (step
1)
Criteria
Points
Temperature above 38OC
1
No cough
1
Tendor anterior cervical adenopathy
1
Tonsillar swelling or exudates
1
Age 3-14 years
1
Age 15-44 years
0
Age 45 years
-1
Table 2b: Total score calculated according to the above
and choose the appropriate management suggested
below according to the total sore throat score (Step 2)
Total score Suggested management
0
No culture or antibiotic is required
1
2
Culture all. Treat with antibiotics only if
3
culture result is positive
4
Culture all. Treat with penicillin on
clinical grounds.
antibiotics in the suspected streptococcal pharyngitis to
prevent the post complication sequels like peritonsillar or
retropharyngeal
abscess,
cervical
lymphadenitis,
mastoiditis, sinusitis, and otitis media rheumatic fever
and glomerulonephritis37,38. However certain studies
have shown that the post complications occur extremely
rare even in the absence of antibiotic therapy39.
Furthermore, no evidence shows that antibiotic therapy
for pharyngitis decreases the incidence of this
complication40. It has been universally accepted that the
penicillin is the first choice treatment of streptococcal
pharyngitis since GAS remains universally susceptible to
penicillin41,42. However ampicillin or amoxicillin are
equally effective and thus can be given in place of
penicillin43. The studies have shown that treatment for 10
days with a single daily dose of amoxicillin is as effective
as treatment with multiple daily doses of penicillin V44,45.
Amoxicillin became the antibiotic of choice in the place
of penicillin in many countries as the penicillin is not
commercially available. The patients who are allergic to
beta-lactam antibiotics
are
administrated
with
macrolides46,47. If the allergic patients, tested to have
hypersensitivity to penicillin are not type I,
cephalosporins should be considered as the alternative
drug. Some studies have shown that cephalosporins has
an efficacy higher than penicillin on GAS48. Further
cephalosporins have been found to be more effective than
penicillin in case of recurrent streptococcal pharyngitis49.
The initiation of antibiotics has showed to be based on the
clinical evidence of streptococcal pharyngitis. Patients
with streptococcal pharyngitis commonly present with
sore throat (generally of sudden onset), severe pain on
swallowing, and fever. Headache, nausea, vomiting, and
abdominal pain may also be present, especially in
children50. Thus the clinicians should clearly ascertain the
possibility of streptococcal pharyngitis in a patient before
initiating the antibiotic therapy. Some clinicians suggest
the use of centor score to identify and treat the cases of

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pharyngitis51,52. The Table 2 shows the calculation of

centor score and the treatment approach according to
it53,54. The rapid antigen tests for identification of beta
haemolytic streptococci have been used in certain
hospital setups. When compared with the golden
standard of throat culture, have reported sensitivities of
65% to 91% and specificities of 62% to 97%55-58. As
these tests have approximately the sensitivity and greater
specificity as that of throat culture, it can be used widely
in all clinics to ascertain the cause of pharyngitis and thus
can initiate the appropriate treatment59.
CONCLUSION
To conclude, the indiscriminate use of antibiotics
especially for adults in not advisable as from the review it
is clear that the pharyngitis in adults are mainly due to
virus. In a clinics a diagnostic and therapeutic rationale
should be created to limit the use of antibiotic treatment
to patients.
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