Sore Throat Differential Diagnosis: A Comprehensive Guide for Clinicians

Pharyngitis, commonly known as a sore throat, is characterized by inflammation of the mucous membranes lining the oropharynx. While often dismissed as a minor ailment, effectively navigating the Sore Throat Differential Diagnosis is crucial for healthcare professionals. The majority of sore throat cases stem from viral or bacterial infections; however, a spectrum of other etiologies, ranging from allergies and trauma to more serious conditions like cancer or systemic diseases, must be considered. Accurate diagnosis is paramount to guide appropriate treatment, alleviate patient discomfort, and prevent potential complications. This article provides a detailed overview of the differential diagnosis of sore throat, enhancing clinicians’ ability to effectively evaluate and manage patients presenting with this common complaint.

Etiology of Sore Throat: Viral, Bacterial, and Beyond

Understanding the diverse causes of pharyngitis is fundamental to constructing an accurate sore throat differential diagnosis. Viral infections are the predominant culprits, accounting for 50% to 80% of sore throat cases. A wide array of viral pathogens can be responsible, with rhinovirus, influenza viruses, adenovirus, coronaviruses, and parainfluenza viruses being the most frequently encountered. Less common viral agents include herpes simplex virus, Epstein-Barr virus (EBV), human immunodeficiency virus (HIV), and coxsackieviruses. Bacterial infections, while less prevalent overall, often lead to more severe presentations.

Group A beta-hemolytic streptococci (GABHS) stands out as the most common bacterial cause, responsible for 5% to 36% of acute pharyngitis cases. However, the bacterial spectrum extends beyond GABHS, encompassing Group B and C streptococci, Chlamydia pneumoniae, Mycoplasma pneumoniae, Haemophilus influenzae, Candida species, Neisseria meningitidis, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Fusobacterium necrophorum, and Corynebacterium diphtheriae. Beyond infectious etiologies, non-infectious factors such as environmental allergies and exposure to chemical irritants can also trigger acute pharyngitis.

It’s also essential to recognize that sore throat can be a presenting symptom of more serious underlying conditions. These include peritonsillar abscess, retropharyngeal abscess, epiglottitis, and Kawasaki disease, all of which necessitate prompt and accurate sore throat differential diagnosis to ensure timely and appropriate intervention.

Epidemiology of Pharyngitis: A Global Perspective

Pharyngitis is a widespread health concern, impacting individuals across all age groups and geographical locations. In the United States alone, emergency departments witnessed over 1.8 million visits for pharyngitis in 2010, with a significant proportion (692,000) involving children under 15 years of age. Young children, particularly those under 5, experience the highest incidence of pharyngitis. While adults are less frequently affected, sore throat remains a common complaint in this population as well.

Globally, pharyngitis rates are notably elevated, particularly in regions where antibiotic overuse is prevalent. This overuse not only contributes to antibiotic resistance but also highlights the importance of accurate sore throat differential diagnosis to avoid unnecessary antibiotic prescriptions for viral infections, which are self-limiting and do not respond to antibacterial agents. Understanding the epidemiological context of pharyngitis underscores the need for judicious diagnostic and therapeutic approaches.

Pathophysiology of Sore Throat: Mechanisms of Inflammation

The sensation of a sore throat arises from the inflammatory response triggered by various etiological agents. Infectious agents, both bacterial and viral, can directly invade the pharyngeal mucosa, initiating inflammation. Certain viruses, such as rhinovirus, may also induce irritation indirectly through postnasal drip and nasal secretions. Regardless of the specific trigger, the common pathophysiological pathway involves local invasion of the pharyngeal mucosa, leading to vasodilation, increased vascular permeability, and the influx of inflammatory cells.

This inflammatory process results in the cardinal signs of pharyngitis: edema (swelling) of the pharyngeal tissues and excessive mucus secretion. These physiological changes contribute to the characteristic symptoms of sore throat, including pain, scratchiness, and difficulty swallowing. Understanding the pathophysiology reinforces the importance of identifying the underlying cause through a thorough sore throat differential diagnosis to target treatment effectively.

History and Physical Examination: Key Differentiators in Sore Throat Diagnosis

A comprehensive history and physical examination are indispensable tools in the sore throat differential diagnosis process. The clinical evaluation aims to distinguish uncomplicated pharyngitis from potentially serious and life-threatening conditions that may present with similar symptoms. Typical features of uncomplicated pharyngitis include fever, tonsillar exudates (white or yellow patches on the tonsils), painful cervical lymphadenopathy (swollen lymph nodes in the neck), pharyngeal erythema (redness of the throat), and ear pain (otalgia). Uncomplicated infectious pharyngitis, whether viral or bacterial, is generally self-limiting, resolving within 5 to 7 days. It is typically bilateral, non-progressive, and lacks trismus (difficulty opening the mouth) or signs of airway obstruction such as stridor (high-pitched breathing sound).

However, certain historical and physical findings can help differentiate between viral and bacterial etiologies and identify more serious conditions within the sore throat differential diagnosis.

Viral Pharyngitis Clues:

• Associated Symptoms: Cough, rhinorrhea (runny nose), conjunctivitis (pink eye), headache, and rash are frequently observed alongside viral sore throats. These accompanying symptoms are less typical in bacterial pharyngitis, particularly streptococcal pharyngitis.

Bacterial Pharyngitis (Specifically GABHS) Clues:

• Abrupt Onset: Streptococcal pharyngitis often presents with a sudden onset of sore throat.
• Lack of Viral URI Symptoms: Absence of cough or rhinorrhea is more suggestive of bacterial rather than viral pharyngitis.
• Classic Triad: Fever, tonsillar exudates, and tender anterior cervical lymphadenopathy are strongly associated with GABHS pharyngitis.

Infectious Mononucleosis (EBV Pharyngitis) Clues:

• Systemic Symptoms: Headache, fever, significant fatigue, myalgia (muscle aches).
• Tonsillar Hypertrophy: Marked enlargement of the tonsils.
• Lymphadenopathy: Both anterior and posterior cervical lymph nodes may be enlarged. Persistent lymphadenopathy and fatigue can last for several weeks.
• Hepatomegaly/Splenomegaly: Enlargement of the liver or spleen should be assessed for, as these can occur in infectious mononucleosis.
• Amoxicillin Rash: Development of a morbilliform rash after amoxicillin administration for presumed streptococcal pharyngitis should raise suspicion for infectious mononucleosis.

Red Flags for Serious Conditions in Sore Throat Differential Diagnosis:

• Retropharyngeal Abscess: Neck stiffness and pain, particularly with neck extension.
• Epiglottitis: Stridor, drooling, and difficulty swallowing.
• Lemierre’s Syndrome (F. necrophorum): Consider in adolescents and young adults with persistent sore throat, fever, and septic thrombophlebitis of the internal jugular vein.
• Gonococcal Pharyngitis (N. gonorrhoeae): Consider in patients with a history of orogenital contact.
• Acute Retroviral Syndrome (HIV): Fever and non-exudative pharyngitis may be present in the early stages of HIV infection.

By carefully considering the patient’s history and physical examination findings, clinicians can narrow the sore throat differential diagnosis and guide further evaluation and management.

Evaluation of Sore Throat: Diagnostic Tools and Strategies

To refine the sore throat differential diagnosis, particularly in cases where bacterial pharyngitis, specifically GABHS, is suspected, various clinical decision rules and diagnostic tests are available.

Clinical Decision Rules:

• Centor Score/Modified Centor Score: This scoring system assigns points for specific clinical criteria to estimate the probability of GABHS pharyngitis.

  Centor Criteria (1 point each):

  1. Tonsillar exudates
  2. Tender anterior cervical lymph nodes
  3. History of fever (temperature ≥ 100.4°F or 38°C)
  4. Absence of cough

  Age Modification: Age is often incorporated into the Modified Centor Score, with points added for ages 3-14 and subtracted for ages 45 and older.

  Score Interpretation and Action:

  • 0-1 points: Low probability of GABHS; no testing or antibiotics generally recommended.
  • 2-3 points: Intermediate probability; Rapid Antigen Detection Test (RADT) recommended.
  • 4+ points: High probability; Empiric antibiotics may be considered, or RADT can be performed.

Laboratory Tests:

• Rapid Antigen Detection Test (RADT): A rapid test to detect GABHS antigens in a throat swab.

  • Specificity: High specificity for GABHS.
  • Sensitivity: Sensitivity varies (70-90%).
  • Positive RADT: Treatment for GABHS pharyngitis is indicated.
  • Negative RADT (especially in children): Throat culture is recommended to rule out GABHS due to potential false-negative results.

• Throat Culture: The gold standard for GABHS detection.

  • Sensitivity: More sensitive than RADT, but results take 24-48 hours.
  • Factors Affecting Sensitivity: Bacterial load, swab collection technique (tonsillar surface preferred), culture medium, and incubation atmosphere.

• Heterophile Antibody Test (Monospot Test): Used to detect infectious mononucleosis (EBV).

  • Sensitivity: 70-92% sensitive, but sensitivity is lower in the first 1-2 weeks of illness and in children under 12.
  • Specificity: 96-100% specific.
  • EBV Serology: Epstein-Barr virus-specific serology is the definitive diagnostic test for infectious mononucleosis if the Monospot test is negative or early in the illness.

• Gonococcal Culture: Thayer-Martin agar culture is used to detect Neisseria gonorrhoeae in cases of suspected gonococcal pharyngitis.

• Candida Testing: Potassium hydroxide (KOH) preparation or Sabouraud agar culture can be used to identify Candida species in suspected cases of fungal pharyngitis.

Imaging Studies:

• Chest X-ray: Generally not needed for routine pharyngitis.
• Lateral Neck X-ray: May be indicated if airway compromise (e.g., epiglottitis) is suspected.
• Computed Tomography (CT) Scan: May be helpful in identifying peritonsillar abscess if clinically suspected.

White blood cell counts and differentials are generally not helpful in distinguishing between viral and bacterial pharyngitis. However, lymphocytosis (>50%) or atypical lymphocytes (>10%) may suggest infectious mononucleosis. A strategic approach to evaluation, incorporating clinical assessment and appropriate diagnostic testing, is essential for accurate sore throat differential diagnosis.

Treatment and Management of Pharyngitis: Targeted and Symptomatic Approaches

Treatment strategies for pharyngitis are guided by the underlying etiology, identified through the sore throat differential diagnosis process.

Antibiotics for Bacterial Pharyngitis (GABHS):

• Indications: Primarily for patients with confirmed GABHS pharyngitis (positive RADT or throat culture).
• Benefits: Reduce symptom duration by 16-24 hours, prevent acute rheumatic fever (a serious complication of untreated strep throat).
• Antibiotic of Choice: Oral penicillin (penicillin V or amoxicillin) for 10 days to ensure eradication of bacteria and prevent rheumatic fever.
• Alternative Antibiotics: Cephalosporins (for mild penicillin allergy), macrolides (azithromycin, clarithromycin), or clindamycin (for penicillin anaphylaxis). Macrolide resistance is a growing concern, making them less preferred first-line agents.
• Infectivity: Patients are generally considered non-infectious after 24 hours of antibiotic therapy.

Symptomatic Treatment for Viral and Bacterial Pharyngitis:

• Pain Relief: Acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) are effective for pain and fever reduction.
• Topical Remedies: Warm saline gargles can provide soothing relief.
• Hydration: Adequate fluid intake is crucial, especially in cases of fever.
• Corticosteroids: Single-dose corticosteroids (e.g., dexamethasone) may be considered to reduce symptom severity, but evidence is limited and not routinely recommended.

Specific Management Considerations:

• Infectious Mononucleosis: Avoidance of contact sports for 6-8 weeks due to the risk of splenic rupture. Treatment is primarily supportive, focusing on symptom relief.
• Gonococcal Pharyngitis: Antibiotic therapy directed against N. gonorrhoeae.
• Candidal Pharyngitis: Antifungal medications.

Antibiotic Stewardship: It’s crucial to emphasize judicious antibiotic use in pharyngitis management. Given that most cases are viral, antibiotics are unnecessary and contribute to antibiotic resistance. Accurate sore throat differential diagnosis is key to guiding antibiotic decisions and promoting responsible antibiotic prescribing practices.

Sore Throat Differential Diagnosis: A Comprehensive List

The sore throat differential diagnosis is broad, encompassing a range of infectious and non-infectious conditions. A systematic approach is essential to consider and exclude alternative diagnoses.

Key Differential Diagnoses to Consider:

• Infectious Causes:

  • Viral Pharyngitis: Rhinovirus, adenovirus, influenza virus, parainfluenza virus, coronavirus, enteroviruses (coxsackievirus, herpangina), respiratory syncytial virus (RSV), herpes simplex virus (HSV), Epstein-Barr virus (EBV – infectious mononucleosis), cytomegalovirus (CMV), HIV (acute retroviral syndrome).
  • Bacterial Pharyngitis: Group A streptococcus (Streptococcus pyogenes), Group C and G streptococci, Arcanobacterium haemolyticum, Corynebacterium diphtheriae (diphtheria), Neisseria gonorrhoeae (gonococcal pharyngitis), Chlamydia pneumoniae, Mycoplasma pneumoniae, Fusobacterium necrophorum (Lemierre’s syndrome).
  • Fungal Pharyngitis: Candida albicans (oral thrush).

• Non-Infectious Causes:

  • Allergic Rhinitis: Postnasal drip can irritate the throat.
  • Gastroesophageal Reflux Disease (GERD): Acid reflux can cause throat irritation.
  • Trauma: Direct injury to the throat.
  • Irritants: Smoke, pollutants, dry air.
  • Vocal Strain: Excessive or improper voice use.
  • Neoplasms (Cancer of the Head and Neck): Less common, but should be considered in persistent or unexplained sore throat, especially in smokers or heavy drinkers.
  • Thyroiditis: Inflammation of the thyroid gland can sometimes cause referred pain to the throat.
  • Peritonsillar Abscess: Collection of pus behind the tonsil, a complication of tonsillitis.
  • Retropharyngeal Abscess: Collection of pus in the space behind the pharynx, a serious deep neck infection.
  • Epiglottitis: Inflammation of the epiglottis, a life-threatening airway obstruction.
  • Kawasaki Disease: A rare childhood illness that can include pharyngitis as a symptom.
  • Airway Obstruction (from any cause): Foreign body aspiration, angioedema, etc.

This comprehensive sore throat differential diagnosis list serves as a guide for clinicians to consider the breadth of possibilities when evaluating patients with sore throat.

Prognosis of Pharyngitis: Generally Favorable

The prognosis for pharyngitis is generally excellent. Both viral and bacterial infections typically resolve spontaneously within 5 to 7 days.

Factors Influencing Prognosis:

• Etiology: Viral pharyngitis is self-limiting. Bacterial pharyngitis (GABHS) responds well to antibiotics, preventing complications like rheumatic fever.
• Treatment Adherence: Compliance with antibiotic regimens for bacterial infections is crucial for complete eradication and prevention of recurrence.
• Antibiotic Resistance: In rare cases, antibiotic resistance may lead to treatment failure in bacterial pharyngitis.

Potential Complications:

While uncommon, complications of bacterial pharyngitis can occur:

• Suppurative Complications: Peritonsillar abscess, retropharyngeal abscess, otitis media, sinusitis, mastoiditis.
• Non-Suppurative Complications: Acute rheumatic fever, post-streptococcal glomerulonephritis.
• Rare but Serious: Epiglottitis (more common in children), toxic shock syndrome.

Mortality from uncomplicated pharyngitis is exceedingly rare, primarily occurring in cases of airway compromise, such as epiglottitis or severe retropharyngeal abscess. In developing countries, rheumatic fever remains a significant concern as a complication of untreated streptococcal pharyngitis, highlighting the importance of timely diagnosis and treatment.

Complications of Pharyngitis: Recognizing and Managing Risks

While most cases of pharyngitis resolve without sequelae, it’s important to be aware of potential complications, particularly those associated with bacterial pharyngitis. Understanding these complications is a key aspect of comprehensive patient care following a sore throat differential diagnosis.

Complications of Bacterial Pharyngitis:

• Peritonsillar Abscess (Quinsy): A localized collection of pus in the peritonsillar space, often presenting with severe sore throat, unilateral tonsillar swelling, uvular deviation, and trismus.
• Retropharyngeal Abscess: A deep neck infection in the retropharyngeal space, more common in young children, characterized by neck stiffness, fever, and potential airway compromise.
• Otitis Media (Middle Ear Infection): Spread of infection to the middle ear, more common in children.
• Sinusitis: Inflammation of the sinuses.
• Mastoiditis: Infection of the mastoid bone, a serious complication of otitis media.
• Acute Rheumatic Fever (ARF): A serious inflammatory condition that can affect the heart, joints, brain, and skin, caused by untreated GABHS pharyngitis. Preventable with antibiotic treatment of strep throat.
• Post-Streptococcal Glomerulonephritis (PSGN): Kidney inflammation following GABHS infection, typically not prevented by antibiotics but usually resolves spontaneously.
• Toxic Shock Syndrome (TSS): A rare but life-threatening condition caused by bacterial toxins, can occur with streptococcal infections.

Early recognition and appropriate management of these complications are crucial to minimize morbidity and ensure optimal patient outcomes. The initial sore throat differential diagnosis plays a role in anticipating potential risks and guiding follow-up care.

Postoperative and Rehabilitation Care: Considerations for Specific Pharyngitis Complications

Routine pharyngitis, whether viral or bacterial, typically does not require postoperative or rehabilitation care. However, certain complications or specific treatments may necessitate specific follow-up measures.

Post-Tonsillectomy Care: Patients undergoing tonsillectomy (surgical removal of tonsils, often for recurrent tonsillitis or peritonsillar abscess) require postoperative care focused on pain management, hydration, and monitoring for bleeding or infection.

Management of Peritonsillar Abscess: Drainage of peritonsillar abscess (needle aspiration or incision and drainage) may be required, followed by antibiotic therapy and pain management.

Rehabilitation for Rheumatic Fever: Patients with acute rheumatic fever require long-term management, including secondary prophylaxis with penicillin to prevent recurrent streptococcal infections and subsequent rheumatic heart disease. Cardiac monitoring and management of heart failure may be necessary in cases of rheumatic carditis.

General Post-Pharyngitis Care:

• Follow-up: Generally, follow-up cultures are not necessary for patients with uncomplicated pharyngitis who have completed antibiotic therapy and are asymptomatic.
• Symptom Management: Continue symptomatic treatment (pain relievers, fluids) as needed until symptoms fully resolve.
• Education: Reinforce patient education regarding hygiene practices (handwashing) to prevent future infections.

Deterrence and Patient Education: Preventing Pharyngitis and Promoting Responsible Antibiotic Use

Patient education is paramount in deterring pharyngitis transmission and promoting responsible healthcare practices. Effective communication regarding the sore throat differential diagnosis and appropriate management is essential.

Key Patient Education Points:

• Viral vs. Bacterial Pharyngitis: Educate patients and parents about the differences between viral and bacterial sore throats. Emphasize that most sore throats are viral and do not require antibiotics.
• Antibiotic Use: Explain that antibiotics are only effective against bacterial infections, specifically GABHS in the context of pharyngitis. Discourage self-treatment with antibiotics for viral sore throats.
• Completing Antibiotic Course: For patients diagnosed with GABHS pharyngitis and prescribed antibiotics, stress the importance of completing the full 10-day course to eradicate the bacteria and prevent rheumatic fever.
• Symptomatic Relief for Viral Pharyngitis: Advise patients with viral sore throats to focus on symptomatic relief with over-the-counter pain relievers (acetaminophen, ibuprofen), rest, and hydration.
• Hygiene Practices: Educate on the importance of frequent handwashing, covering coughs and sneezes, and avoiding close contact with sick individuals to prevent the spread of respiratory infections, including pharyngitis.
• Vaccination: Recommend annual influenza vaccination to prevent influenza-related pharyngitis. Vaccination against Corynebacterium diphtheriae (DPT vaccine) is important to prevent diphtheria.

By empowering patients with knowledge and promoting responsible antibiotic use, clinicians can contribute to improved public health and reduce the burden of antibiotic resistance. Accurate sore throat differential diagnosis is the foundation for providing targeted and effective patient education.

Pearls and Other Issues in Pharyngitis Management

Several key “pearls” and considerations can optimize pharyngitis management and enhance patient care.

• Antibiotic Overuse: Recognize and actively combat the tendency to overuse antibiotics for acute pharyngitis. Emphasize that the majority of cases are viral and self-limiting.
• Clinical Decision Rules: Utilize clinical decision rules like the Centor Score to guide the need for testing and antibiotic therapy in suspected GABHS pharyngitis.
• Rapid Strep Tests: Employ RADTs judiciously, understanding their limitations (sensitivity) and the need for throat culture confirmation in children with negative RADT results.
• Symptomatic Management: Prioritize symptomatic treatment for viral pharyngitis and as adjunctive therapy for bacterial pharyngitis.
• Differential Diagnosis Breadth: Maintain a broad sore throat differential diagnosis to avoid missing less common but potentially serious conditions.
• Patient Education is Key: Invest time in patient education to promote responsible antibiotic use, preventive hygiene practices, and appropriate self-care measures.

Enhancing Healthcare Team Outcomes in Pharyngitis Management

Optimal pharyngitis management requires a collaborative interprofessional team approach. Effective coordination among physicians, nurses, pharmacists, and other healthcare providers is essential to ensure comprehensive patient care and improve outcomes.

Interprofessional Team Strategies:

• Collaborative Diagnosis and Treatment Planning: Physicians, nurses, and pharmacists can collaborate to ensure accurate sore throat differential diagnosis, appropriate antibiotic selection (when indicated), and effective symptom management strategies.
• Medication Reconciliation and Counseling: Pharmacists play a crucial role in medication reconciliation, ensuring appropriate antibiotic dosing and duration, and counseling patients on antibiotic adherence and potential side effects.
• Patient Education and Follow-up: Nurses and other healthcare professionals can reinforce patient education messages regarding viral vs. bacterial pharyngitis, antibiotic use, hygiene practices, and symptom management. Nurses can also play a key role in follow-up, monitoring patient progress, and addressing any concerns.
• Antibiotic Stewardship Programs: Interprofessional teams are essential for implementing and promoting antibiotic stewardship programs within healthcare settings to optimize antibiotic use and combat antibiotic resistance.
• Communication and Coordination: Clear and consistent communication among team members is vital to ensure seamless patient care and address any patient needs or concerns promptly.

By leveraging the expertise of each team member and fostering effective communication, healthcare teams can optimize the management of pharyngitis, improve patient outcomes, and promote responsible healthcare practices. Accurate sore throat differential diagnosis, coupled with collaborative care, is the cornerstone of successful pharyngitis management.

Outcomes of Pharyngitis: Generally Favorable with Proper Management

The vast majority of pharyngitis cases have a favorable outcome, resolving spontaneously within 7-10 days.

Factors Influencing Outcomes:

• Etiology: Viral pharyngitis typically resolves without specific treatment. Bacterial pharyngitis (GABHS), when appropriately treated with antibiotics, generally leads to rapid symptom improvement and prevents serious complications.
• Treatment Compliance: Adherence to prescribed antibiotic regimens is essential for optimal outcomes in bacterial pharyngitis.
• Early Diagnosis and Management of Complications: Prompt recognition and management of complications, such as peritonsillar abscess or rheumatic fever, are critical to prevent adverse sequelae.

Potential for Treatment Failure:

• Antibiotic Resistance: Rarely, antibiotic resistance in bacterial pharyngitis may lead to treatment failure.
• Poor Patient Compliance: Non-adherence to antibiotic therapy can result in treatment failure and increased risk of complications.
• Untreated Close Contacts: In cases of recurrent streptococcal pharyngitis, evaluation and treatment of close contacts may be necessary to prevent ongoing transmission.

Mortality from pharyngitis in developed countries is extremely rare, typically associated with airway obstruction. Complications occur in a small percentage of patients (<1%) and can include otitis media, pneumonia, nephritis, and meningitis. However, with appropriate sore throat differential diagnosis, timely treatment, and effective interprofessional care, the prognosis for pharyngitis remains overwhelmingly positive.

Review Questions

[Original article’s review questions section would be included here if present and relevant to the expanded content. As the original article only mentions “Access free multiple choice questions on this topic” without providing them directly, this section is omitted to adhere to the instruction of only including title and content.]

References

[Original article’s references section – kept as is]

1.Frost HM, McLean HQ, Chow BDW. Variability in Antibiotic Prescribing for Upper Respiratory Illnesses by Provider Specialty. J Pediatr. 2018 Dec;203:76-85.e8. [PubMed: 30195553]

2.Alzahrani MS, Maneno MK, Daftary MN, Wingate L, Ettienne EB. Factors Associated with Prescribing Broad-Spectrum Antibiotics for Children with Upper Respiratory Tract Infections in Ambulatory Care Settings. Clin Med Insights Pediatr. 2018;12:1179556518784300. [PMC free article: PMC6055249] [PubMed: 30046262]

3.Gottlieb M, Long B, Koyfman A. Clinical Mimics: An Emergency Medicine-Focused Review of Streptococcal Pharyngitis Mimics. J Emerg Med. 2018 May;54(5):619-629. [PubMed: 29523424]

4.Brennan-Krohn T, Ozonoff A, Sandora TJ. Adherence to guidelines for testing and treatment of children with pharyngitis: a retrospective study. BMC Pediatr. 2018 Feb 09;18(1):43. [PMC free article: PMC5807738] [PubMed: 29426305]

5.Faden H, Callanan V, Pizzuto M, Nagy M, Wilby M, Lamson D, Wrotniak B, Juretschko S, St George K. The ubiquity of asymptomatic respiratory viral infections in the tonsils and adenoids of children and their impact on airway obstruction. Int J Pediatr Otorhinolaryngol. 2016 Nov;90:128-132. [PMC free article: PMC7132388] [PubMed: 27729119]

6.Follmann D, Huang CY, Gabriel E. Who really gets strep sore throat? Confounding and effect modification of a time-varying exposure on recurrent events. Stat Med. 2016 Oct 30;35(24):4398-4412. [PMC free article: PMC5048538] [PubMed: 27313096]

7.Dunmire SK, Hogquist KA, Balfour HH. Infectious Mononucleosis. Curr Top Microbiol Immunol. 2015;390(Pt 1):211-40. [PMC free article: PMC4670567] [PubMed: 26424648]

8.Akhtar M, Van Heukelom PG, Ahmed A, Tranter RD, White E, Shekem N, Walz D, Fairfield C, Vakkalanka JP, Mohr NM. Telemedicine Physical Examination Utilizing a Consumer Device Demonstrates Poor Concordance with In-Person Physical Examination in Emergency Department Patients with Sore Throat: A Prospective Blinded Study. Telemed J E Health. 2018 Oct;24(10):790-796. [PMC free article: PMC6205037] [PubMed: 29470127]

9.Yamamoto S, Gu Y, Fujitomo Y, Kanai N, Yamahata Y, Saito H, Hashimoto T, Ohmagari N. Development and efficacy of a clinician-targeted refresher course for treating nonpneumonia respiratory tract infections. J Gen Fam Med. 2018 Jul;19(4):127-132. [PMC free article: PMC6030038] [PubMed: 29998042]

10.Bird C, Winzor G, Lemon K, Moffat A, Newton T, Gray J. A Pragmatic Study to Evaluate the Use of a Rapid Diagnostic Test to Detect Group A Streptococcal Pharyngitis in Children With the Aim of Reducing Antibiotic Use in a UK Emergency Department. Pediatr Emerg Care. 2021 May 01;37(5):e249-e251. [PubMed: 30045356]

11.Piltcher OB, Kosugi EM, Sakano E, Mion O, Testa JRG, Romano FR, Santos MCJ, Di Francesco RC, Mitre EI, Bezerra TFP, Roithmann R, Padua FG, Valera FCP, Lubianca Neto JF, Sá LCB, Pignatari SSN, Avelino MAG, Caixeta JAS, Anselmo-Lima WT, Tamashiro E. How to avoid the inappropriate use of antibiotics in upper respiratory tract infections? A position statement from an expert panel. Braz J Otorhinolaryngol. 2018 May-Jun;84(3):265-279. [PMC free article: PMC9449220] [PubMed: 29588108]

12.Baugh RF. IDSA guidelines on group A streptococcal pharyngitis vis-a-vis tonsillectomy recommendations. Clin Infect Dis. 2013 Apr;56(8):1194-5. [PubMed: 23362294]

13.Gerber MA, Baltimore RS, Eaton CB, Gewitz M, Rowley AH, Shulman ST, Taubert KA. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. Circulation. 2009 Mar 24;119(11):1541-51. [PubMed: 19246689]

14.Yoon YK, Park CS, Kim JW, Hwang K, Lee SY, Kim TH, Park DY, Kim HJ, Kim DY, Lee HJ, Shin HY, You YK, Park DA, Kim SW. Guidelines for the Antibiotic Use in Adults with Acute Upper Respiratory Tract Infections. Infect Chemother. 2017 Dec;49(4):326-352. [PMC free article: PMC5754344] [PubMed: 29299900]

15.Norhayati MN, Ho JJ, Azman MY. Influenza vaccines for preventing acute otitis media in infants and children. Cochrane Database Syst Rev. 2017 Oct 17;10(10):CD010089. [PMC free article: PMC6485791] [PubMed: 29039160]

16.Norton LE, Lee BR, Harte L, Mann K, Newland JG, Grimes RA, Myers AL. Improving Guideline-Based Streptococcal Pharyngitis Testing: A Quality Improvement Initiative. Pediatrics. 2018 Jul;142(1) [PubMed: 29925574]

17.Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, Papola D, Lytvyn L, Vandvik PO, Merglen A, Guyatt GH, Agoritsas T. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017 Sep 20;358:j3887. [PMC free article: PMC5605780] [PubMed: 28931508]

Disclosures

[Original article’s disclosures section – kept as is]

Disclosure: Robert Wolford declares no relevant financial relationships with ineligible companies.

Disclosure: Amandeep Goyal declares no relevant financial relationships with ineligible companies.

Disclosure: Shehla Yasin Belgam Syed declares no relevant financial relationships with ineligible companies.

Disclosure: Timothy Schaefer declares no relevant financial relationships with ineligible companies.