What is the treatment for acute tonsillopharyngitis?

Treatment of Acute Tonsillopharyngitis

Penicillin V oral (250 mg twice or three times daily for children; 250 mg four times daily or 500 mg twice daily for adolescents and adults) for 10 days remains the first-line treatment for bacterial tonsillopharyngitis, with amoxicillin as an equivalent alternative offering better palatability and once-daily dosing options. 1, 2

Initial Management Strategy: Selective Antibiotic Use

The decision to prescribe antibiotics should be guided by clinical severity and microbiological confirmation, not reflexive prescribing:

• Patients with 0-2 Centor criteria should NOT receive antibiotics for symptom relief, as the likelihood of bacterial infection is low and antibiotics provide no meaningful benefit. 1

• Patients with 3-4 Centor criteria warrant discussion about antibiotic use, weighing modest benefits (1-2 days symptom reduction) against side effects, antibiotic resistance, and costs. 1

• Delayed prescribing is a valid and recommended strategy when diagnosis is uncertain, allowing patients to initiate antibiotics only if symptoms worsen or persist beyond 2-3 days. 1, 3

• Microbiological testing (rapid antigen detection test or throat culture) is strongly recommended before prescribing antibiotics to confirm Group A β-hemolytic streptococcal infection, regardless of clinical scores. 4, 5, 6

First-Line Antibiotic Treatment

Penicillin-Based Regimens (First Choice)

Penicillin V remains the gold standard due to proven efficacy over five decades, narrow spectrum, safety profile, lack of resistance development, and low cost. 1, 2

Dosing for Penicillin V:

• Children: 250 mg twice or three times daily for 10 days 2
• Adolescents and adults: 250 mg four times daily OR 500 mg twice daily for 10 days 2

Amoxicillin is an equivalent alternative with advantages in pediatric populations:

• Children: 50 mg/kg once daily (or 25 mg/kg twice daily) for 10 days 2, 4, 7
• Better taste acceptance in children 1
• Caution: Avoid amoxicillin in older children/adolescents with possible Epstein-Barr virus infection due to severe rash risk 1

Benzathine penicillin G intramuscular is reserved for compliance concerns:

• <27 kg: 600,000 units single dose 2
• ≥27 kg: 1,200,000 units single dose 2

Critical Point: 10-Day Duration is Non-Negotiable

The full 10-day course is essential for penicillin and amoxicillin to maximize bacterial eradication and prevent rheumatic fever, despite shorter courses showing inferior outcomes. 1, 2, 8 Shorter 5-day penicillin courses demonstrate significantly lower eradication rates and should be avoided. 2

Alternative Antibiotics for Penicillin Allergy

Non-Anaphylactic Penicillin Allergy

First-generation cephalosporins are the preferred alternatives:

• Cephalexin: 20 mg/kg/dose twice daily for 10 days 2, 4
• Cefadroxil: 30 mg/kg once daily for 10 days 2, 4

While meta-analyses show cephalosporins have statistically superior bacteriologic cure rates (OR 2.29-2.34), these differences are clinically insignificant and do not justify routine use over penicillin in non-allergic patients. 1

Anaphylactic Penicillin Allergy

When β-lactams are contraindicated, use:

• Clindamycin: 7 mg/kg/dose three times daily for 10 days (preferred for reliability) 2, 4
• Azithromycin: 12 mg/kg once daily for 5 days 2, 4, 9
• Clarithromycin: 7.5 mg/kg/dose twice daily for 10 days 2

Important caveat: Macrolides should be used cautiously due to increasing Group A streptococcal resistance in many regions, making them less reliable than clindamycin. 2, 5 Azithromycin shows equivalent efficacy to penicillin in clinical trials but resistance patterns vary geographically. 1, 9

Symptomatic Management (Essential for All Patients)

Ibuprofen or acetaminophen (paracetamol) are recommended for pain and fever relief, providing meaningful symptom improvement regardless of antibiotic use. 1, 4, 5

Avoid aspirin in children due to Reye's syndrome risk. 5

Corticosteroids are NOT routinely recommended as adjunctive therapy, with only weak evidence supporting single-dose use in severe cases with high Centor scores, and insufficient safety data for routine use. 1, 5

Management of Treatment Failures and Recurrent Cases

When initial penicillin therapy fails (persistent symptoms or positive culture after treatment):

Consider alternative regimens:

• Clindamycin oral 2
• Amoxicillin-clavulanate oral 2
• Benzathine penicillin G IM with rifampin 2

Do NOT perform follow-up cultures in asymptomatic patients who completed appropriate therapy, as this identifies carriers rather than treatment failures. 2, 4

Common Pitfalls to Avoid

1. Overtreating viral pharyngitis: 70-95% of tonsillopharyngitis cases are viral and do not benefit from antibiotics. 5 Clinical features suggesting viral etiology include cough, rhinorrhea, hoarseness, conjunctivitis, and oral ulcers. 5

2. Treating chronic carriers: Patients who carry Group A streptococci asymptomatically and develop viral infections test positive but don't require antibiotics. 5 Repeated treatment of carriers is harmful without benefit. 5

3. Using antibiotics to prevent complications in low-risk patients: Prevention of purulent complications (peritonsillar abscess, otitis media) is NOT an indication for antibiotics in patients with low clinical probability of bacterial infection. 3

4. Prescribing inadequate duration: Shorter courses compromise bacterial eradication and increase rheumatic fever risk. 2, 8

5. Choosing broad-spectrum agents unnecessarily: Cephalosporins and macrolides should be reserved for specific indications (allergy, treatment failure), not used routinely despite marginally better bacteriologic cure rates. 1