What are the Philippine guidelines for managing Acute Tonsillopharyngitis?

Philippine Guidelines for Acute Tonsillopharyngitis

Diagnostic Approach

Testing for Group A Streptococcus (GAS) is mandatory before prescribing antibiotics, as clinical features alone cannot reliably distinguish bacterial from viral pharyngitis. 1

When to Test

• Perform rapid antigen detection test (RADT) and/or throat culture when patients present with sore throat unless overt viral features are present (rhinorrhea, cough, oral ulcers, hoarseness) 1
• In children and adolescents, negative RADTs must be backed up by throat culture due to higher risk of rheumatic fever 1
• In adults, back-up throat cultures after negative RADT are not routinely necessary given the low incidence of GAS and exceptionally low risk of acute rheumatic fever 1
• Do not test children younger than 3 years unless risk factors exist (e.g., older sibling with illness) 1

Clinical Features Suggesting GAS

• Sudden onset sore throat with fever >38°C 2, 3
• Tonsillar exudates 1
• Tender anterior cervical lymphadenopathy 1, 2
• Absence of cough 2, 3
• Palatal petechiae 1
• Presentation in winter or early spring 1
• Scarlatiniform rash 1

Important caveat: Even with all clinical features present, GAS is confirmed only 35-50% of the time, making laboratory confirmation essential 1

Treatment Algorithm

For Confirmed GAS Pharyngitis

First-line treatment is penicillin V or amoxicillin for 10 days—this duration is non-negotiable to prevent rheumatic fever and maximize bacterial eradication. 1, 2, 3

Patients Without Penicillin Allergy

• Penicillin V: Children 250 mg two or three times daily; Adolescents/adults 250 mg four times daily or 500 mg twice daily for 10 days 1
• Amoxicillin: 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg) for 10 days 1, 4
• Penicillin G benzathine IM: <27 kg: 600,000 U; ≥27 kg: 1,200,000 U as single dose 1

Patients With Penicillin Allergy (Non-Anaphylactic)

• Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 1, 2
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1

Patients With Penicillin Allergy (Anaphylactic)

• Clindamycin: 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1, 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 5
• Clarithromycin: 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 1

Critical pitfall: Macrolide resistance varies geographically and temporally; these are not first-line agents 1

For Viral Pharyngitis

• Symptomatic treatment only: analgesics (acetaminophen, NSAIDs), adequate hydration 1, 6
• Do not use aspirin in children 1
• Topical agents with benzalkonium chloride + tyrothricin + benzocaine may provide additional symptom relief 7, 8

Management of Recurrent Episodes

Early Recurrence (Within 2 Weeks of Completing Therapy)

For documented recurrent GAS within 2 weeks, switch to agents with higher pharyngeal eradication rates rather than repeating the same antibiotic. 1, 2

• Clindamycin: 20-30 mg/kg/day in three doses (maximum 300 mg per dose) for 10 days 1, 2
• Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in three doses (maximum 2,000 mg amoxicillin/day) for 10 days 2
• Penicillin V + rifampin: Penicillin V 50 mg/kg/day in four doses for 10 days plus rifampin 20 mg/kg/day in one dose for the last 4 days 1, 2

Chronic Carriers

• Multiple recurrences may represent viral infections in a chronic GAS carrier rather than true bacterial infections 1, 2
• Consider treatment for chronic carriage only in specific situations: community outbreak of rheumatic fever/glomerulonephritis, family history of rheumatic fever, excessive patient anxiety, or when tonsillectomy is being considered solely for carrier state 1

Adjunctive Therapy

• Analgesics/antipyretics (acetaminophen, NSAIDs) for moderate to severe symptoms or high fever 1
• Do not use corticosteroids routinely 1
• Warm salt water gargles for patients old enough to perform them 2

What NOT to Do

• Never prescribe antibiotics without laboratory confirmation of GAS (except when obvious viral features present) 1, 2, 3
• Never use short courses (<10 days) of penicillin or amoxicillin—they are less effective for GAS eradication 2, 9
• Never perform routine follow-up throat cultures on asymptomatic patients who completed appropriate therapy 1, 2
• Never routinely test or treat asymptomatic household contacts 1
• Never use antistreptococcal antibody titers for acute diagnosis—they reflect past, not current infection 1

Red Flags Requiring Urgent Evaluation

Evaluate immediately for life-threatening complications if patient presents with: 3

• Difficulty swallowing or drooling
• Neck tenderness or swelling
• Trismus
• Toxic appearance

These may indicate peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome 3, 6