What is the treatment for pharyngitis with prominent adenoids and palatine tonsils?

Treatment of Pharyngitis with Prominent Adenoids and Palatine Tonsils

For pharyngitis with prominent adenoids and palatine tonsils, penicillin remains the treatment of choice due to its proven efficacy, safety, narrow spectrum, and low cost when Group A Streptococcus (GAS) is confirmed. 1

Diagnostic Approach

• First determine if the pharyngitis is caused by Group A Streptococcus (GAS) through either throat culture or rapid antigen detection test (RADT) 1
• Clinical features suggesting GAS pharyngitis include sore throat, fever >100.4°F (38°C), tonsillar exudates, and cervical adenopathy 2
• A negative RADT should be confirmed with a throat culture due to lower sensitivity 1
• Viral pharyngitis is more likely if cough, coryza (runny nose), or diarrhea are present 2

Antibiotic Treatment for GAS Pharyngitis

First-line Treatment:

• Penicillin V: 50 mg/kg/day in 4 doses for 10 days (maximum 2000 mg/day) 1
• Amoxicillin: 50 mg/kg once daily for 10 days (maximum 1000 mg) - equally effective as penicillin and more palatable, especially for children 1
• Benzathine penicillin G (intramuscular): 600,000 units for patients <27 kg and 1,200,000 units for patients ≥27 kg - preferred for patients unlikely to complete oral therapy 1

For Penicillin-Allergic Patients:

• Non-anaphylactic allergy: First-generation cephalosporins (e.g., cephalexin, cefadroxil) for 10 days 1
• Anaphylactic allergy:
  • Clindamycin: 20-30 mg/kg/day in 3 doses for 10 days (maximum 300 mg/dose) 1
  • Clarithromycin: 15 mg/kg/day in 2 doses for 10 days (maximum 250 mg twice daily) 1
  • Azithromycin: 12 mg/kg once daily for 5 days (maximum 500 mg) 1, 3

Supportive Care

• Pain management: NSAIDs such as ibuprofen or acetaminophen are effective for reducing pain and fever 1
• Avoid aspirin in children due to risk of Reye syndrome 1
• Topical relief: Warm salt water gargles for patients old enough to gargle 1
• Adequate hydration and rest 4
• Corticosteroids are not recommended for routine use in pharyngitis 1

Management of Recurrent Episodes

• For patients with recurrent GAS pharyngitis, consider whether they are experiencing true infections or are chronic carriers with viral infections 1
• For chronic carriers with recurrent symptoms, consider one of these regimens: 1
  • Clindamycin: 20-30 mg/kg/day in 3 doses for 10 days (maximum 300 mg/dose) 1
  • Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses for 10 days 1, 5
  • Penicillin V with rifampin: Penicillin V for 10 days plus rifampin 20 mg/kg/day for the last 4 days of treatment 1

Special Considerations

• Tonsillectomy is not recommended solely to reduce frequency of GAS pharyngitis 1, 2
• Routine post-treatment throat cultures are not recommended for asymptomatic patients 1
• Testing of asymptomatic household contacts is generally not recommended 1
• Fusobacterium necrophorum may be a significant pathogen in adolescents and young adults with pharyngitis and should be considered in treatment-resistant cases 6

Follow-up

• If symptoms persist or worsen despite appropriate antibiotic therapy, consider: 1
  • Poor medication adherence
  • Antibiotic resistance (though penicillin resistance in GAS has not been documented) 1
  • Development of suppurative complications (peritonsillar abscess) 6
  • Viral infection in a GAS carrier 1

Remember that proper diagnosis and appropriate antibiotic selection are crucial to prevent complications such as acute rheumatic fever, reduce symptoms, decrease infectivity, and allow rapid return to normal activities 1, 7.