Management of Acute Tonsillipharyngitis
For acute tonsillipharyngitis, confirm Group A Streptococcus (GAS) infection with rapid antigen detection testing (RADT) or throat culture before prescribing antibiotics, and treat confirmed bacterial cases with penicillin V or amoxicillin for 10 days. 1, 2
Diagnostic Approach
Initial Clinical Assessment
The first step is determining whether the infection is viral or bacterial, as this fundamentally changes management 1, 2. However, clinical features alone are insufficient—even experienced physicians cannot reliably differentiate between viral and bacterial causes based solely on presentation 3.
Viral features that suggest testing is NOT needed: 3
- Presence of cough
- Rhinorrhea
- Hoarseness
- Conjunctivitis
- Discrete oral ulcers or ulcerative stomatitis
Bacterial (GAS) features that warrant testing: 3
- Sudden onset of sore throat
- Fever >38°C
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough
- Palatal petechiae
Risk Stratification Using Clinical Scoring
Use the modified McIsaac scoring system to guide testing decisions 4:
Score 1 point for each:
- Temperature ≥38°C
- Absence of cough
- Tender anterior cervical adenopathy
- Tonsillar swelling/exudate
- Age <15 years
Subtract 1 point for:
- Age ≥45 years
Management based on score: 4
- Score 0-1: Neither antibiotics nor culture required
- Score 2-3: Perform RADT/culture, base antibiotic decision on result
- Score 4-5: Either initiate antibiotics immediately or perform testing
Laboratory Confirmation
Microbiological testing is mandatory before prescribing antibiotics for suspected bacterial pharyngitis 1, 3. Clinical impression alone leads to antibiotic overuse 3.
- RADT: A positive result is diagnostic for GAS and requires treatment 3
- Throat culture: Gold standard; required when RADT is negative in children and adolescents 3
- Do NOT use: Complete blood counts or inflammatory markers (CRP, procalcitonin) are not required for most patients and have poor diagnostic accuracy 3, 5
Treatment of Confirmed Bacterial (GAS) Tonsillipharyngitis
First-Line Antibiotic Therapy
Penicillin V oral for 10 days remains the first-line treatment due to its narrow spectrum, efficacy, tolerability, and cost 4, 1. Amoxicillin for 10 days is an acceptable alternative 1, 2.
The 10-day duration is critical—it maximizes bacterial eradication and prevents complications like rheumatic fever 1, 2. Short courses of 5 days with standard-dose penicillin are less effective and should be avoided 1, 5.
Penicillin-Allergic Patients
For non-anaphylactic penicillin allergy: 1
- First-generation cephalosporins (cefalexin, cefadroxil) for 10 days
For anaphylactic penicillin allergy: 1
- Clindamycin, azithromycin, or clarithromycin for 10 days
Symptomatic Treatment
All patients should receive symptomatic relief regardless of antibiotic use 1:
- NSAIDs (ibuprofen) or acetaminophen for pain and fever
- Warm salt water gargles for patients old enough to perform them
Topical agents containing benzalkonium chloride, tyrothricin, and benzocaine may provide additional symptom relief and shorten disease duration 5.
Management of Viral Tonsillipharyngitis
No antibiotics are indicated for viral infections 1, 2. Treatment consists entirely of supportive care with analgesics and adequate hydration 6.
Recurrent Tonsillipharyngitis
When Symptoms Return Shortly After Treatment
If symptoms recur within 2 weeks of completing therapy, consider treatment failure, chronic GAS carriage with viral superinfection, or reinfection 1.
Alternative antibiotic regimens for documented recurrent GAS: 1
- Clindamycin: 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days
- Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses (maximum 2000 mg amoxicillin/day) for 10 days
- Penicillin with rifampin: Penicillin V 50 mg/kg/day in 4 doses for 10 days plus rifampin 20 mg/kg/day in 1 dose for the last 4 days
Consideration for Tonsillectomy
Watchful waiting is strongly recommended unless Paradise criteria are met 2, 7:
Tonsillectomy should be considered only when:
- ≥7 well-documented episodes in the preceding year, OR
- ≥5 episodes per year for 2 consecutive years, OR
- ≥3 episodes per year for 3 consecutive years
All episodes must be disabling, adequately treated, and well-documented 2. Tonsillectomy is NOT recommended solely to reduce GAS pharyngitis frequency 1.
Follow-Up Recommendations
Do NOT perform follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1, 2. This is a common pitfall that wastes resources without clinical benefit.
Critical Pitfalls to Avoid
- Never initiate antibiotics without confirming GAS infection through testing 1, 2—this is the single most important intervention to reduce inappropriate antibiotic use
- Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective 2
- Never prescribe antibiotic courses shorter than 10 days for GAS (except in specific high-dose regimens) 1, 5
- Never rely on clinical features alone to differentiate viral from bacterial infection 3
- Never perform routine follow-up cultures in asymptomatic patients 1, 2
Special Considerations
The "delayed antibiotic prescription" strategy—where antibiotics are prescribed but patients are instructed to wait 2-3 days before filling the prescription if symptoms don't improve—is appropriate and highly effective in doubtful cases 5. This approach reduces antibiotic consumption while maintaining patient safety.
Rheumatic fever prevention, while historically important, is now of limited concern in high-income countries due to low incidence 4. However, prevention of suppurative complications (peritonsillar abscess, cervical lymphadenitis) remains relevant, though this is NOT a specific indication for empiric antibiotics in most patients 5.