Treatment of Acute Tonsillopharyngitis
Diagnostic Approach Before Treatment
The first critical step is determining whether the infection is bacterial (Group A Streptococcus) or viral, as this fundamentally changes management—antibiotics should only be prescribed for confirmed bacterial cases. 1
When to Test for Bacterial Infection
- Testing is indicated when clinical features suggest bacterial etiology: sudden onset sore throat, fever >38.3°C (101°F), tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough 1, 2
- Do not test or treat empirically when viral features predominate: cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis, or gradual onset 1, 3
- Children <3 years old generally do not require testing unless high-risk factors exist (e.g., older sibling with confirmed GAS infection) 1
Testing Method
- Use rapid antigen detection testing (RADT) as first-line diagnostic tool 1, 2
- In children and adolescents, negative RADT must be confirmed with throat culture due to lower sensitivity 1
- In adults, negative RADT does not require backup culture given low rheumatic fever risk 1
- Positive RADT does not need confirmation—specificity is high 1
Treatment for Confirmed Bacterial (GAS) Tonsillopharyngitis
First-Line Antibiotic Therapy
Penicillin or amoxicillin for 10 days is the treatment of choice based on narrow spectrum, proven efficacy, low cost, and absence of resistance. 1, 2
Penicillin-Based Regimens (Non-Allergic Patients)
- Penicillin V: 250 mg orally twice daily for 10 days (adults); 50 mg/kg/day divided twice daily for 10 days (children, maximum 500 mg/dose) 1, 2, 4
- Amoxicillin: 500 mg orally once or twice daily for 10 days (adults); 40-50 mg/kg/day once or twice daily for 10 days (children) 1, 2, 5
- Benzathine penicillin G: Single intramuscular injection (alternative when compliance is concern) 1, 6
Penicillin-Allergic Patients
- Non-anaphylactic allergy: First-generation cephalosporin (cephalexin or cefadroxil) for 10 days 1, 2, 5
- Anaphylactic allergy:
Critical Treatment Principles
- The 10-day duration is essential for bacterial eradication and prevention of rheumatic fever—shorter courses of standard-dose penicillin are less effective 1, 2, 8
- The only exception is azithromycin (5 days) or high-dose penicillin four times daily (5 days), though the latter is not standard practice 1
- Do not prescribe antibiotics without microbiological confirmation unless testing is unavailable and clinical suspicion is very high 1, 3
Treatment for Viral Tonsillopharyngitis
Antibiotics provide no benefit for viral pharyngitis and may cause harm—symptomatic treatment is the only appropriate management. 1, 3
Symptomatic Management (Viral or Bacterial)
- Acetaminophen or ibuprofen for pain and fever control (strong recommendation) 1
- Avoid aspirin in children due to Reye syndrome risk 1
- Warm salt water gargles for patients old enough to gargle 1, 2
- Topical anesthetics (lozenges, sprays with benzocaine, lidocaine) may provide temporary relief but represent choking hazard in young children 1
What NOT to Do
- Corticosteroids are not recommended as adjunctive therapy—minimal benefit (approximately 5 hours pain reduction) does not justify potential adverse effects 1, 3
- Do not prescribe antibiotics for viral pharyngitis 3
Management of Recurrent Tonsillopharyngitis
Distinguish True Recurrence from Chronic Carriage
When patients return with positive GAS testing shortly after treatment, consider three scenarios: 2, 9
- True recurrent infection: New GAS acquisition from contacts
- Treatment failure: Non-compliance or inadequate initial therapy
- Chronic GAS carrier with viral infection: Positive test but viral symptoms (cough, rhinorrhea)
Chronic carriers do not require antibiotic treatment—they are at minimal risk for complications and unlikely to spread infection. 1, 9
Treatment for True Recurrent GAS Pharyngitis
When recurrence occurs within weeks of completing appropriate therapy: 2, 9, 10
- Clindamycin: 20-30 mg/kg/day in 3 divided doses for 10 days (maximum 300 mg/dose) 2, 9
- Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 divided doses for 10 days (maximum 2000 mg amoxicillin/day) 2, 9, 10
- 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 2, 9
- Intramuscular benzathine penicillin G (alternative) 9
Role of Tonsillectomy
- Tonsillectomy is not recommended solely to reduce GAS pharyngitis frequency 1, 9
- May consider for patients meeting specific criteria: ≥7 episodes in past year, ≥5 episodes/year for 2 years, or ≥3 episodes/year for 3 years, with documentation of each episode including fever >38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 1
- Benefits are modest and limited to first year post-operatively 1
Common Pitfalls to Avoid
- Prescribing antibiotics without microbiological confirmation in low-risk patients 1, 3
- Using short courses (<10 days) of standard-dose penicillin—increases treatment failure risk 1, 2
- Routine post-treatment testing in asymptomatic patients who completed appropriate therapy 1, 2
- Treating asymptomatic household contacts 1
- Confusing chronic GAS carriers with active infection—carriers with viral symptoms do not need antibiotics 1, 9
- Using broad-spectrum antibiotics when narrow-spectrum penicillin is effective 1, 2
- Prescribing corticosteroids routinely—minimal benefit does not justify risks 1
Special Populations
Patients with History of Rheumatic Fever
- Require continuous antimicrobial prophylaxis (secondary prevention) to prevent recurrent attacks 9, 6
- Duration: 10 years or until age 40 (with carditis); 5 years or until age 21 (without carditis) 9, 6
- Prophylaxis regimen: Penicillin V 250 mg orally twice daily, or benzathine penicillin G monthly, or sulfadiazine/erythromycin if penicillin-allergic 9, 4, 6
Pregnant Patients with Chlamydial Pharyngitis
- Erythromycin 500 mg orally four times daily for at least 7 days (or 500 mg every 12 hours for 14 days if not tolerated) 4