What are the treatments for complications of sore throat?

Treatment of Complications of Sore Throat

Penicillin V is the first-line treatment for streptococcal pharyngitis and its complications, administered at 250-500 mg 2-3 times daily for 10 days to prevent suppurative and non-suppurative complications. 1, 2

Identifying Complications of Sore Throat

Complications of sore throat can be categorized as:

1. Suppurative (local) complications:

   • Peritonsillar abscess (quinsy)
   • Cervical lymphadenitis
   • Acute otitis media
   • Acute sinusitis
   • Mastoiditis

2. Non-suppurative (systemic) complications:

   • Acute rheumatic fever
   • Acute glomerulonephritis

Antibiotic Treatment for Complications

First-line Treatment:

• Penicillin V: 250 mg 2-3 times daily for children, 500 mg 2-3 times daily for adolescents/adults for 10 days 1, 2
  • Complete the full 10-day course even if symptoms improve before completion to prevent acute rheumatic fever 2

Alternative Regimens (for penicillin allergies):

• Non-anaphylactic penicillin allergy: First-generation cephalosporins for 10 days 2
• Anaphylactic penicillin allergy:
  • Clindamycin: 300-450 mg orally three times daily for 10 days 2
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 2, 3
  • Clarithromycin: Note that significant resistance exists in some regions 2

Management of Specific Complications

Peritonsillar Abscess (Quinsy)

• Requires prompt antibiotic treatment plus possible surgical drainage
• Polymicrobial infection but Group A streptococcus is the main organism associated with the disease 1
• May require hospitalization for IV antibiotics and hydration in severe cases

Acute Rheumatic Fever Prevention

• Complete the full 10-day antibiotic course is crucial 2
• Continuous antimicrobial prophylaxis is recommended for patients with a history of rheumatic fever to prevent recurrences 2

Suppurative Complications (Otitis Media, Sinusitis)

• Antibiotics significantly reduce the incidence of acute otitis media (Peto OR 0.21) 4
• For acute sinusitis, targeted antibiotics based on likely pathogens

Supportive Care for All Complications

• Pain and fever management:
  • Acetaminophen or NSAIDs (avoid aspirin in children due to Reye's syndrome risk) 2
  • Cold liquids or ice chips for symptomatic relief 2
  • Avoid hot liquids, spicy foods, and hard foods that may irritate the throat 2

Infection Control Measures

• Patients should complete at least 24 hours of antibiotics before returning to school or work to reduce transmission risk 2
• Implement hand hygiene and other infection control measures to prevent spread 2

Important Considerations

• Most cases of pharyngitis (80-90%) are viral and do not require antibiotics 2
• Use Centor Criteria to determine likelihood of streptococcal pharyngitis before initiating antibiotics 2
• Treating streptococcal pharyngitis with appropriate antibiotics reduces risk of complications significantly 2, 4
• The incidence of serious complications like acute rheumatic fever has decreased significantly in developed countries but remains important in high-risk populations 5, 4

Algorithm for Management of Suspected Complications

1. Assess for red flags requiring immediate attention:

   • Difficulty breathing or swallowing
   • Drooling
   • Voice changes
   • Neck swelling or limited neck movement
   • Severe systemic symptoms

2. Evaluate using Centor Criteria for bacterial etiology:

   • Tonsillar exudates
   • Tender anterior cervical lymph nodes
   • Lack of cough
   • Fever

3. Initiate appropriate antibiotic therapy based on suspected complication and patient factors

   • Start penicillin V for 10 days if no allergies
   • Use appropriate alternatives for penicillin-allergic patients

4. Monitor for resolution of symptoms and development of additional complications

   • Follow up within 24-48 hours for severe cases
   • Ensure completion of full antibiotic course