From the Guidelines
Management of tonsillitis with a negative strep test typically involves supportive care since most cases are viral in origin. Patients should be advised to rest, maintain adequate hydration, and use over-the-counter pain relievers such as acetaminophen (500-1000 mg every 6 hours, not exceeding 4000 mg daily) or ibuprofen (400-600 mg every 6-8 hours with food) to manage pain and fever. Warm salt water gargles (1/2 teaspoon of salt in 8 ounces of warm water) several times daily can provide symptomatic relief. Cold beverages, ice pops, or throat lozenges may also help soothe throat discomfort.
Key Considerations
- Antibiotics are generally not recommended for negative strep tests since they are ineffective against viral infections and contribute to antibiotic resistance 1.
- If symptoms persist beyond 7-10 days, worsen significantly, or if the patient develops difficulty breathing or swallowing, they should be reevaluated as this could indicate a bacterial superinfection or complications requiring different management.
- The rationale for this approach is that 70-85% of tonsillitis cases in adults are viral, and unnecessary antibiotic use increases resistance risks while providing no benefit for viral infections.
Additional Guidance
- Patients with symptoms suggestive of group A streptococcal pharyngitis should be tested by rapid antigen detection test and/or culture for group A Streptococcus, and treated with antibiotics only if they have confirmed streptococcal pharyngitis 1.
- For patients with confirmed acute group A streptococcal pharyngitis, antibiotics should be prescribed for a duration likely to eradicate group A Streptococcus from the pharynx (usually 10 days) with an appropriate narrow-spectrum antibiotic 1.
From the Research
Management Approach for Tonsillitis with Negative Strep Test
- The management approach for a patient with tonsillitis and a negative streptococcal (strep) test focuses on supportive care, as the majority of cases are caused by viral infections 2.
- According to the study published in the American Family Physician, treatment is focused on supportive care, and if group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic 2.
- However, in cases where the strep test is negative, the approach may vary, and some studies suggest that withholding antibiotics altogether may not be advisable 3.
- A study published in the Telemedicine Journal and E-Health suggests that the best clinical management of patients with sore throat depends on both the clinical probability of group A streptococcal infection and clinical judgments that incorporate the importance ratings of the individual patients as well as practice circumstances 4.
- In terms of antibiotic treatment, some studies have shown that penicillin may not always be effective, and other antibiotics such as cephalosporins may be superior in eradicating group A beta-hemolytic Streptococcus 5.
- A comparative study published in the Reviews of Infectious Diseases found that bacampicillin, penicillin V, and amoxicillin were all effective in treating acute tonsillitis and/or pharyngitis due to beta-hemolytic streptococci, with no significant differences in clinical or bacteriologic responses 6.
Recurrent Tonsillitis
- For patients with recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years 2.