What is the recommended treatment for tonsillar spots with a negative streptococcus A (strep A) test?

Treatment for Tonsillar Spots with Negative Strep A Testing

For patients with tonsillar spots and a negative strep A test, symptomatic treatment with analgesics is recommended without antibiotics, as most cases are viral in origin. 1, 2

Diagnostic Considerations

When evaluating tonsillar spots with a negative strep A test:

• Negative rapid antigen detection tests (RADTs) for strep A have high specificity (90-95%), making bacterial infection unlikely 3
• Follow-up throat culture after a negative RADT is not necessary in both children and adults 1
• Most cases of tonsillitis (70-95%) are viral in origin, not bacterial 2
• Clinical scoring systems like Centor criteria can help assess likelihood of streptococcal infection:
  • Fever >38°C
  • Absence of cough
  • Tender anterior cervical lymphadenopathy
  • Tonsillar exudate
  • Age consideration (higher likelihood in children/adolescents)

Treatment Recommendations

First-line Treatment (Symptomatic Management)

• Analgesics/antipyretics:
  • Ibuprofen or paracetamol (acetaminophen) for pain and fever relief 1
  • These medications address symptoms while the viral infection runs its course

When to Consider Antibiotics

Antibiotics should only be considered if:

1. High clinical suspicion for bacterial infection despite negative test (3-4 Centor criteria)
2. Severe symptoms or high-risk patient (immunocompromised)
3. Worsening symptoms or development of complications

If antibiotics are deemed necessary (which is rare with negative strep testing):

• First choice: Penicillin V (250 mg four times daily or 500 mg twice daily for 10 days) 3
• For penicillin-allergic patients: Azithromycin (500 mg once daily for 5 days in adults; 12 mg/kg once daily for 5 days in children) 3, 4

Adjunctive Treatments

• Corticosteroids: Not routinely recommended but may be considered in adults with severe symptoms 1
• Zinc gluconate: Not recommended 1
• Herbal treatments/acupuncture: Insufficient evidence to recommend 1
• Hydration: Encourage adequate fluid intake
• Rest: Advise rest until fever subsides and symptoms improve

Follow-up Considerations

• Most viral tonsillitis resolves within 7-10 days
• Advise patients to return if:
  • Symptoms worsen after 3-4 days
  • Inability to swallow fluids
  • Development of peritonsillar abscess symptoms (severe pain, voice changes, trismus)
  • Persistent fever >3 days

Special Considerations

• Recurrent tonsillitis: Watchful waiting is recommended if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years 3, 2
• Tonsilloliths (tonsil stones): These can cause spots on tonsils and are managed expectantly; surgical intervention is rarely required 2
• Prevention: Hand hygiene and avoiding close contact with infected individuals are important preventive measures 3

Remember that overuse of antibiotics contributes to antibiotic resistance and can disrupt normal protective pharyngeal flora, potentially leading to treatment failures in future bacterial infections 5.