Treatment of Odynophagia Due to Throat Infection

Diagnostic Approach

Odynophagia (painful swallowing) with throat infection requires identification of the causative organism to guide appropriate treatment 2, 3
In immunocompromised patients, especially those with HIV, Candida is the most common cause of esophageal symptoms and odynophagia 1, 4
Presence of oropharyngeal candidiasis (thrush) with odynophagia strongly suggests Candida esophagitis in immunocompromised patients 4

The Infectious Diseases Society of America recommends first-line treatment with fluconazole 200-400 mg daily for 14-21 days 1, 3
For fluconazole-refractory disease, the American College of Gastroenterology suggests itraconazole solution 200 mg daily OR voriconazole 200 mg twice daily for 14-21 days 1
Alternative options for refractory cases include echinocandins (micafungin 150 mg daily, caspofungin 70 mg loading dose then 50 mg daily, or anidulafungin 200 mg daily) for 14-21 days, as recommended by the Clinical Infectious Diseases society 1
For patients unable to tolerate oral therapy, amphotericin B deoxycholate 0.3-0.7 mg/kg daily is recommended by the Infectious Diseases Society of America 1
For recurrent infections, chronic suppressive therapy with fluconazole 100-200 mg three times weekly is suggested by the Clinical Infectious Diseases society 1

The Centers for Disease Control and Prevention recommends acyclovir or valacyclovir for herpes simplex virus 4
Ganciclovir is recommended for immunocompromised patients with cytomegalovirus by the MMWR Recommendations and Reports 4

In HIV-positive patients with odynophagia, a therapeutic trial with fluconazole is often appropriate before invasive diagnostic procedures, as recommended by the Infectious Diseases Society of America and the MMWR Recommendations and Reports 1, 4
For patients with dysphagia/odynophagia who don't respond to initial therapy, endoscopy is warranted to obtain specimens for definitive diagnosis, according to the American College of Radiology and the Clinical Gastroenterology and Hepatology society 2, 5
Immunocompromised patients with severe symptoms should undergo endoscopy for specimen acquisition rather than empiric therapy, as recommended by the American College of Radiology and the MMWR Recommendations and Reports 4, 5
For patients with swallowing difficulties due to neurological causes, referral to a speech-language pathologist for swallowing evaluation and therapy is recommended by the American College of Chest Physicians and the Clinical Nutrition society 6, 7

For patients with severe odynophagia affecting oral intake, ensuring adequate hydration and nutrition is crucial, as recommended by the Infectious Diseases Society of America 8
Consideration of a soft or liquid diet temporarily is suggested by the Clinical Nutrition society 7

Treating empirically without considering the patient's immune status and likely pathogens is a pitfall to avoid, as warned by the Clinical Gastroenterology and Hepatology society and the MMWR Recommendations and Reports 2, 4
Failing to recognize that non-response to antifungal therapy may indicate resistant Candida species or a different pathogen is a mistake to avoid, according to the Infectious Diseases Society of America and the Clinical Gastroenterology and Hepatology society 1, 3