What are the latest guidelines for treating acute tonsillopharyngitis in pediatric patients?

Management of Acute Tonsillopharyngitis in Pediatric Patients

Penicillin V or amoxicillin for 10 days remains the first-line treatment for confirmed Group A Streptococcal (GAS) tonsillopharyngitis in children, with amoxicillin preferred due to better palatability and once-daily dosing. 1, 2

Diagnostic Approach

Do not test children under 3 years of age for GAS pharyngitis, as rheumatic fever is extremely rare in this age group and most cases are viral 2.

For children ≥3 years:

• Use Rapid Antigen Detection Test (RADT) as the initial diagnostic tool 1
• A positive RADT indicates treatment (high specificity) 1
• A negative RADT must be confirmed with throat culture in children (unlike adults), as sensitivity can be unacceptably low 1
• Clinical scoring alone (Centor/McIsaac) without laboratory confirmation is insufficient in pediatric populations 1

First-Line Antibiotic Treatment

For confirmed GAS pharyngitis, prescribe:

Preferred Regimens:

• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days 1, 2

  • Preferred in younger children due to better taste and simplified dosing 1

• Penicillin V: 250 mg 2-3 times daily for children <27 kg (60 lbs); 500 mg 2-3 times daily for children ≥27 kg and adolescents, for 10 days 1, 2

Alternative for Penicillin Allergy (Non-Type I Hypersensitivity):

• Narrow-spectrum cephalosporins (cefdinir, cefpodoxime, cefuroxime) for 10 days 1

For Type I Penicillin Allergy:

• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 3
• Clarithromycin: 15 mg/kg/day divided twice daily (maximum 250 mg BID) for 10 days 1
• Clindamycin: 20 mg/kg/day divided in 3 doses (maximum 1.8 g/day) for 10 days 1

Critical caveat: Macrolides (azithromycin, clarithromycin) should NOT be first-line due to increasing resistance rates; some strains show 20-30% resistance, with eradication rates as low as 14-19% for resistant isolates 1, 4

Treatment Duration

The full 10-day course is essential for penicillin and amoxicillin to prevent rheumatic fever, even if symptoms resolve earlier 1, 2.

• Shorter courses (5 days) of penicillin show inferior bacterial eradication compared to 10 days 1
• Short-course cephalosporins (5 days) may achieve comparable eradication but are not recommended as first-line due to cost and broader spectrum 1, 5
• Patients become non-contagious after 24 hours of appropriate antibiotic therapy 2

Symptomatic Management

Pain control is a priority regardless of antibiotic use:

• Acetaminophen or ibuprofen for moderate to severe symptoms or high fever 1, 2
• Never use aspirin in children due to Reye syndrome risk 2
• Topical agents may provide additional symptom relief but are not substitutes for antibiotics in confirmed GAS 6

When NOT to Treat with Antibiotics

Avoid antibiotics in:

• Children with 0-2 Centor criteria and negative testing 1
• Suspected viral pharyngitis (most cases in children are viral, only 20-30% are GAS) 2
• Carriers with concurrent viral illness (elevated antibody titers indicate past, not current, infection) 1

Delayed prescribing strategy (observation for 48-72 hours with symptomatic treatment) is appropriate for uncertain cases with low clinical suspicion 1, 6

Common Pitfalls to Avoid

• Do not use amoxicillin in older children/adolescents with suspected mononucleosis due to severe rash risk 1
• Do not rely on clinical features alone (exudative tonsillitis is NOT specific for streptococcal etiology in children) 6
• Do not use sulfonamides, trimethoprim, tetracyclines, or fluoroquinolones for GAS pharyngitis 1
• Do not prescribe macrolides as first-line unless true penicillin allergy exists 1, 3
• Benzathine penicillin G (600,000 U for <27 kg; 1,200,000 U for ≥27 kg) intramuscularly once is an alternative when compliance is a concern 1