What is the treatment for tonsillar pharyngitis?

Treatment of Tonsillar Pharyngitis

For confirmed bacterial (Group A Streptococcus) tonsillar pharyngitis, penicillin V or amoxicillin for 10 days remains the first-line treatment, with cephalexin as the preferred second-line option and macrolides reserved only for severe penicillin allergy. 1, 2

Initial Diagnostic Approach

Before initiating antibiotics, confirmation of bacterial etiology is essential:

• Rapid antigen detection testing (RADT) and/or throat culture should be performed to confirm Group A Streptococcus (GAS) before prescribing antibiotics 1, 2, 3
• Most tonsillar pharyngitis is viral in origin and does not require antibiotic treatment 1
• A watchful waiting strategy with symptom relief and no antibiotics is the recommended first-choice approach for suspected viral pharyngitis 1
• In children, negative RADT results should be confirmed with throat culture, though this may not be necessary in adults given their lower risk of rheumatic fever 1

First-Line Antibiotic Treatment

For confirmed bacterial pharyngitis:

Penicillin Options

• Penicillin V (phenoxymethylpenicillin): 250 mg 2-3 times daily for children <27 kg; 500 mg 2-3 times daily for children ≥27 kg, adolescents, and adults for 10 days 1, 2
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days, or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2
• Benzathine penicillin G (single intramuscular dose): 600,000 U for patients <27 kg; 1,200,000 U for patients ≥27 kg 1, 2

The 10-day treatment duration is critical to maximize bacterial eradication and prevent rheumatic fever—shorter courses of standard-dose penicillin are less effective 1, 3, 4

Rationale for Penicillin

Penicillin remains the drug of choice because of:

• Proven efficacy in preventing rheumatic fever (RR 0.27; 95% CI 0.12-0.60) 1
• Narrow spectrum of activity 1
• Cost-effectiveness 1
• No documented GAS resistance to penicillin 1
• Reduction in suppurative complications including peritonsillar abscess (RR 0.15; 95% CI 0.05-0.47) and acute otitis media (RR 0.30; 95% CI 0.15-0.58) 1

Second-Line Treatment (Penicillin Allergy)

For Non-Anaphylactic Penicillin Allergy

• Cephalexin (cefalexin): 20 mg/kg/dose twice daily (maximum 500 mg/dose) for 10 days 1, 2, 3
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 2
• Cephalosporins show lower rates of clinical relapse compared to penicillin (OR 0.55; 95% CI 0.31-0.99) 1
• Avoid cephalosporins in patients with immediate (type I) hypersensitivity to penicillin 1

For Severe/Anaphylactic Penicillin Allergy

• Clindamycin: 20 mg/kg per day divided in 3 doses (maximum 1.8 g/day or 300 mg/dose) for 10 days 1, 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 2, 5
• Clarithromycin: 15 mg/kg per day divided twice daily (maximum 250 mg twice daily) for 10 days 1, 2

Important Caveats About Macrolides

• Macrolides should NOT be used as first-line therapy due to increasing resistance rates 1, 6
• Cephalexin is preferred over macrolides in regions with high macrolide resistance, even for penicillin-allergic patients 1
• Azithromycin showed no difference compared to penicillin for symptom resolution (OR 1.11; 95% CI 0.92-1.35) but has higher rates of late bacteriological recurrence (OR 1.31; 95% CI 1.16-1.48) 1
• In clinical trials, azithromycin was clinically and microbiologically superior to penicillin V at Days 14 and 30, with bacteriologic eradication rates of 95% vs 73% at Day 14 5

Treatment of Recurrent or Relapsing Pharyngitis

For patients with documented recurrent GAS pharyngitis or early relapse after appropriate treatment:

• Clindamycin: 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days 3, 7
• Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses (maximum 2000 mg amoxicillin/day) for 10 days 3, 7
• Penicillin V 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 3

Evidence suggests clindamycin and amoxicillin-clavulanate are superior to penicillin for preventing future attacks in patients with recurrent APT, though these studies had moderate risk of bias 7

Common Pitfalls to Avoid

• Do not prescribe antibiotics without microbiological confirmation of GAS infection—this leads to massive antibiotic overprescribing 1, 3, 8
• Do not use courses shorter than 10 days for standard penicillin therapy—this increases bacteriologic failure rates from 2-10% to approximately 30% 3, 4
• Do not use macrolides as first-line therapy when penicillin or cephalosporins are appropriate 1, 6
• Do not perform routine follow-up throat cultures in asymptomatic patients who completed appropriate therapy 3, 9
• Do not use sulfonamides, trimethoprim, tetracyclines, or fluoroquinolones for GAS pharyngitis—these are not acceptable alternatives 1

Supportive Care

All patients should receive symptomatic treatment regardless of antibiotic use:

• NSAIDs (ibuprofen) or acetaminophen for pain and fever 3
• Warm salt water gargles for patients old enough to perform them 3