What is the recommended management for viral pharyngitis?

Management of Viral Pharyngitis

Viral pharyngitis should be managed with supportive care only, without antibiotics, focusing on symptom relief with analgesics/antipyretics such as acetaminophen or NSAIDs. 1, 2

Diagnosis and Differentiation from Bacterial Pharyngitis

Proper management begins with accurate diagnosis, as treatment differs significantly between viral and bacterial causes:

Clinical Features Suggesting Viral Etiology:

• Presence of cough
• Rhinorrhea (runny nose)
• Hoarseness
• Oral ulcers
• Absence of fever
• Absence of tonsillar exudates
• Absence of tender cervical lymphadenopathy 1, 2

Testing Recommendations:

• Testing for Group A Streptococcus (GAS) is not recommended when clinical features strongly suggest viral etiology 1
• The Centor Criteria can help determine the likelihood of streptococcal pharyngitis:
  • Tonsillar exudates
  • Tender anterior cervical lymph nodes
  • Lack of cough
  • Fever
  • Patients with 0-2 Centor criteria are unlikely to have GAS and do not require testing 2, 3

Treatment Approach for Viral Pharyngitis

Supportive Care (First-line Management):

1. Analgesics/Antipyretics:

   • Acetaminophen or NSAIDs for pain and fever relief 1, 2, 4
   • Avoid aspirin in children due to risk of Reye's syndrome 1

2. Hydration and Comfort Measures:

   • Cold liquids or ice chips
   • Gargling with cold water
   • Avoiding hot liquids and spicy or hard foods that may irritate the throat 2

3. Throat Lozenges:

   • Medicated throat lozenges used every two hours can provide effective symptom relief 4

What to Avoid:

• Antibiotics: Not indicated for viral pharyngitis and contribute to antibiotic resistance 1, 3, 5
• Corticosteroids: Not recommended as adjunctive therapy for routine pharyngitis 1

Special Considerations

Children Under 3 Years:

• Diagnostic studies for GAS pharyngitis are not indicated for children <3 years old as:
  • Acute rheumatic fever is rare in this age group
  • Incidence of streptococcal pharyngitis is uncommon
  • Classic presentation of streptococcal pharyngitis is uncommon 1

Return to School/Work:

• Since viral pharyngitis does not require antibiotics, standard recommendations for avoiding transmission include:
  • Proper hand hygiene
  • Avoiding sharing utensils or drinks
  • Covering mouth when coughing or sneezing 2

Common Pitfalls to Avoid

1. Unnecessary Antibiotic Prescribing:

   • Over 25% of children prescribed antibiotics for pharyngitis do not require them according to guidelines 5
   • Antibiotics are ineffective against viral infections and contribute to antibiotic resistance

2. Inadequate Symptom Management:

   • NSAIDs are more effective than acetaminophen for fever and pain associated with pharyngitis 4

3. Misdiagnosis:

   • Distinguishing between viral and GAS pharyngitis clinically is challenging 3
   • Rely on clinical features and selective testing when appropriate

By focusing on supportive care and symptom management while avoiding unnecessary antibiotics, viral pharyngitis can be effectively managed with minimal complications and reduced healthcare costs.