What is the recommended treatment for acute tonsillar pharyngitis?

Treatment of Acute Tonsillar Pharyngitis

Penicillin V or amoxicillin for 10 days is the first-line treatment for confirmed Group A Streptococcal (GAS) acute tonsillar pharyngitis, based on their narrow spectrum, proven efficacy, low cost, and absence of documented resistance. 1

Diagnostic Approach Before Treatment

Testing is essential to confirm GAS infection before initiating antibiotics, as most acute pharyngitis is viral and does not require antimicrobial therapy. 1

• Perform rapid antigen detection testing (RADT) or throat culture in patients with clinical features suggesting bacterial infection (sudden onset sore throat, fever, tonsillar exudate, tender anterior cervical lymphadenopathy, absence of cough). 1, 2
• In children and adolescents, confirm negative RADT results with throat culture due to variable sensitivity of rapid tests, as missing GAS infection risks acute rheumatic fever. 1
• In adults, RADT alone without culture backup is acceptable given the extremely low risk of acute rheumatic fever in this population. 1
• Do not test or treat children under 3 years old routinely, as acute rheumatic fever is rare and classic streptococcal pharyngitis is uncommon in this age group, unless specific risk factors exist (e.g., older sibling with GAS). 1

First-Line Antibiotic Treatment

Penicillin-based regimens remain the gold standard because GAS has never developed resistance to penicillin, making these agents reliably effective. 1, 3

Preferred Options (Choose One):

• Penicillin V: Children <27 kg: 250 mg orally 2-3 times daily for 10 days; Children ≥27 kg, adolescents, and adults: 500 mg orally 2-3 times daily for 10 days 1
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg/day) orally for 10 days 1, 3
• Benzathine penicillin G: Single intramuscular injection of 600,000 units for patients <27 kg; 1,200,000 units for patients ≥27 kg 1

The American Academy of Pediatrics specifically recommends amoxicillin as first-line in children due to its narrow spectrum, high efficacy, excellent safety profile, and low cost. 3 The 10-day duration is critical for maximal pharyngeal eradication and prevention of acute rheumatic fever. 1, 3

Penicillin-Allergic Patients

For patients with documented penicillin allergy, alternative regimens depend on the type of hypersensitivity reaction. 1

Non-Anaphylactic Penicillin Allergy:

• First-generation cephalosporins for 10 days: Cephalexin 20 mg/kg/dose twice daily (maximum 500 mg/dose) or Cefadroxil 30 mg/kg once daily (maximum 1 g) 1

Immediate (Type I) Hypersensitivity or Anaphylaxis:

• Clindamycin: 20 mg/kg/day divided in 3 doses (maximum 1.8 g/day) for 10 days 1
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 4
• Clarithromycin: 15 mg/kg/day divided twice daily (maximum 250 mg twice daily) for 10 days 1

Important caveat: Macrolide resistance in GAS varies geographically and temporally, making these agents less reliable than penicillins or cephalosporins. 1 They should not be used as first-line therapy when penicillins are appropriate. 2

Adjunctive Symptomatic Treatment

Antibiotics address the infection but do not provide immediate symptom relief. 1

• Acetaminophen or NSAIDs (ibuprofen) for moderate to severe throat pain and fever control 1
• Never use aspirin in children due to risk of Reye syndrome 1, 3
• Corticosteroids are not recommended despite minimal reduction in pain duration (approximately 5 hours), given the self-limited nature of GAS pharyngitis, efficacy of analgesics, and potential adverse effects of systemic steroids 1

Critical Treatment Principles

Complete the full 10-day antibiotic course even when symptoms improve after 2-3 days, as premature discontinuation decreases effectiveness and may contribute to treatment failure. 3, 2 Skipping doses or stopping early does not adequately eradicate GAS from the pharynx and increases risk of complications. 3

Keep children home from school until 24 hours after starting antibiotics and fever-free without antipyretics to prevent transmission. 3

Common Pitfalls to Avoid

• Do not initiate antibiotics without confirming GAS infection through testing, as this leads to inappropriate antimicrobial use in viral pharyngitis. 1, 2
• Do not use clinical scoring alone (e.g., Centor criteria) without microbiological confirmation in children, as this results in unacceptably high rates of inappropriate antibiotic therapy. 1
• Do not routinely perform follow-up throat cultures or RADT after completing appropriate treatment in asymptomatic patients. 1, 2
• Do not test or treat asymptomatic household contacts unless they develop symptoms. 1, 3
• Do not use broad-spectrum antibiotics (fluoroquinolones, tetracyclines, sulfonamides, trimethoprim) when narrow-spectrum penicillins are effective. 1, 2

Management of Recurrent Episodes

Patients presenting with multiple episodes of pharyngitis within months require careful evaluation. 1

• Consider that the patient may be a chronic GAS carrier experiencing intercurrent viral infections rather than true recurrent bacterial infections. 1, 2
• GAS carriers do not require antimicrobial therapy and are unlikely to spread infection or develop complications like acute rheumatic fever. 1, 2
• Tonsillectomy is not recommended solely to reduce frequency of GAS pharyngitis and should only be considered when meeting Paradise criteria (≥7 episodes in 1 year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years, with documented fever, adenopathy, exudate, or positive GAS testing). 1, 2

When to Seek Further Evaluation

Monitor for signs requiring urgent assessment or hospital admission. 5

• Severe dysphagia with inability to swallow or maintain hydration 5
• Respiratory distress or stridor 5
• Peritonsillar abscess (severe unilateral throat pain, trismus, uvular deviation, "hot potato voice") requires drainage and IV antibiotics 5
• Persistent high fever >104°F (40°C) or fever lasting beyond 48-72 hours of appropriate antibiotic therapy 3, 5
• Signs of Lemierre syndrome (internal jugular vein thrombophlebitis): persistent fever, neck swelling, septic appearance 5

Most patients with uncomplicated acute GAS tonsillopharyngitis can be safely managed as outpatients with appropriate oral antibiotics and supportive care. 5