What is the treatment for a 17-year-old patient with a sore throat and enlarged tonsils?

Treatment for a 17-Year-Old with Sore Throat and Enlarged Tonsils

For a 17-year-old with sore throat and enlarged tonsils, the first-line treatment should be testing for Group A Streptococcus using rapid antigen detection test (RADT) and/or culture, followed by appropriate targeted therapy based on test results. 1

Diagnostic Approach

1. Clinical Assessment using Centor Criteria:

   • Fever >38.3°C
   • Tonsillar exudates
   • Tender anterior cervical adenopathy
   • Absence of cough
   • Higher scores (3-4) indicate higher likelihood of streptococcal infection 1

2. Laboratory Testing:

   • For patients with 3-4 Centor criteria: Perform rapid antigen detection test (RADT) 1
   • If RADT is negative but clinical suspicion remains high: Throat culture 1
   • Note: If RADT is performed and negative, throat culture is not necessary 1

Treatment Algorithm

If Group A Streptococcus is Confirmed:

1. First-line Antibiotic:

   • Penicillin V for 10 days 1
   • Dosage for adolescents: Adult dosing appropriate at this age

2. Alternative Antibiotics (if penicillin allergic):

   • Azithromycin 12 mg/kg once daily for 5 days (not to exceed 500 mg/day) 2
   • Clindamycin (for recurrent infections) 3

If Tests are Negative (Likely Viral Tonsillitis):

1. Symptomatic Treatment:

   • Ibuprofen or paracetamol for pain relief 1
   • Adequate hydration 4
   • Throat lozenges for local pain relief 1
   • Salt water gargles (though limited evidence for efficacy) 1

2. Avoid Unnecessary Treatments:

   • Antibiotics should not be used for likely viral infections (0-2 Centor criteria) 1
   • Zinc gluconate is not recommended 1
   • Herbal treatments and acupuncture have inconsistent evidence 1

Special Considerations

When to Consider Tonsillectomy:

Tonsillectomy should be considered only if the patient meets specific criteria:

• ≥7 episodes of documented streptococcal tonsillitis in the past year, OR
• ≥5 episodes per year for 2 consecutive years, OR
• ≥3 episodes per year for 3 consecutive years 3, 5

Important Cautions:

• Watchful waiting is strongly recommended if the frequency criteria for tonsillectomy are not met 3
• Many patients with recurrent tonsillitis improve over time without surgery 3
• Surgical risks include post-operative pain, bleeding, dehydration, and anesthetic complications 3

Red Flags Requiring Urgent Attention:

• Difficulty breathing or swallowing
• Asymmetric tonsillar swelling (possible peritonsillar abscess)
• Severe systemic symptoms
• In adolescents with severe pharyngitis, consider Lemierre syndrome which requires urgent diagnosis and treatment 1

Follow-up Recommendations

• If symptoms worsen or do not improve within 48-72 hours, reassessment is needed
• Complete the full course of antibiotics if prescribed, even if symptoms resolve quickly
• Ensure adequate hydration and pain control throughout the illness

The evidence clearly shows that most cases of tonsillitis are viral (70-95%) 6, and antibiotics should only be used when bacterial infection is confirmed. This approach balances the modest benefits of antibiotics against potential side effects, impact on microbiota, increased bacterial resistance, and unnecessary costs 1.