Principles of appropriate antibiotic use for acute pharyngitis in adults: Background

The following principles of appropriate antibiotic use for adults with acut e pharyngitis apply to immunocompetent adults without complicated comorbid conditions, such as chronic lung or heart disease, and history of rheumatic fever. They do not apply during known outbreaks of group A streptococcus. 1. Group A beta -hemolytic streptococcus (GABHS) is the causal agent in app roximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limited illness, for which supportive ca re only is needed. 2. Antibiotic treatment of adult pharyngitis benefits only those patients w ith GABHS infection. All patients with pharyngitis should be offered approp riate doses of analgesics and antipyretics, as well as other supportive car e. 3. Limit antibiotic prescriptions to patients who are most likely to have G ABHS infection. Clinically screen all adult patients with pharyngitis for t he presence of the four Center criteria: history of fever, tonsillar exudat es, no cough, and tender anterior cervical lymphadenopathy (lymphadenitis). Do not test or treat patients with none or only one of these criteria, sin ce these patients are unlikely to have GABHS infection. For patients with t wo or more criteria the following strategies are appropriate: a) Test patie nts with two, three, or four criteria by using a rapid antigen test, and li mit antibiotic therapy to patients with positive test results; b) test pati ents with two or three criteria by using a rapid antigen test and limit ant ibiotic therapy to patients with positive test results or patients with fou r criteria; or c) do not use any diagnostic tests, and limit antibiotic the rapy to patients with three or four criteria. 4. Throat cultures are not recommended for the routine primary evaluation o f adults with pharyngitis or for confirmation of negative results on rapid antigen tests when the test sensitivity exceeds 80%. Throat cultures may be indicated as part of investigations of outbreaks of GABHS disease, for mon itoring the development and spread of antibiotic resistance, or when such p athogens as gonococcus are being considered. 5. The preferred antibiotic for treatment of acute GABHS pharyngitis is pen icillin, or erythromycin in a penicillin-allergic patient.