What medications are used to treat acute tonsillopharyngitis?

Medications for Acute Tonsillopharyngitis

Test First, Then Treat Based on Results

Antibiotics should only be prescribed for confirmed Group A Streptococcal (GAS) pharyngitis—test patients with symptoms suggestive of bacterial infection (persistent fever, anterior cervical adenitis, tonsillar exudates, absence of cough) using rapid antigen detection test and/or culture before prescribing antibiotics. 1, 2

Antibiotic Treatment for Confirmed GAS Pharyngitis

First-Line Treatment (Non-Allergic Patients)

• Penicillin V or amoxicillin for 10 days is the treatment of choice based on narrow spectrum, proven efficacy, low cost, and complete absence of resistance. 1, 2

• 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). 2

• 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). 2, 3

• The full 10-day course is essential—shortening by even a few days dramatically increases treatment failure rates and risk of acute rheumatic fever. 2, 4

Penicillin-Allergic Patients: Treatment Algorithm

For non-immediate (non-anaphylactic) penicillin allergy:

• First-generation cephalosporins are preferred alternatives with strong, high-quality evidence. 2, 4

• Cephalexin: 500 mg orally twice daily for 10 days (adults); 20 mg/kg/dose twice daily for 10 days (children, maximum 500 mg/dose). 2, 4

• Cefadroxil: 30 mg/kg once daily for 10 days (children). 4

• Cross-reactivity risk is only 0.1% in patients with non-severe, delayed penicillin reactions. 4

For immediate/anaphylactic penicillin allergy:

• Avoid all beta-lactams including cephalosporins due to up to 10% cross-reactivity risk. 2, 4

• Clindamycin is the preferred choice: 300 mg orally three times daily for 10 days (adults); 7 mg/kg/dose three times daily for 10 days (children, maximum 300 mg/dose). 2, 4

• Clindamycin has only ~1% resistance rate in the United States and demonstrates high efficacy even in chronic carriers. 2, 4

Macrolide alternatives (less preferred):

• Azithromycin: 500 mg once daily for 5 days (adults); 12 mg/kg once daily for 5 days (children, maximum 500 mg). 2, 4

• Clarithromycin: 250 mg twice daily for 10 days (adults); 7.5 mg/kg/dose twice daily for 10 days (children, maximum 250 mg/dose). 4

• Erythromycin: 250-500 mg four times daily for 10 days (adults); 20-40 mg/kg/day divided 2-3 times daily for 10 days (children). 4, 5

• Macrolide resistance is 5-8% in the United States and varies geographically—clindamycin is more reliable when beta-lactams cannot be used. 2, 4

Symptomatic Treatment (All Patients)

Analgesic therapy should be offered to all patients regardless of whether antibiotics are prescribed:

• Acetaminophen (paracetamol): Preferred analgesic with strong evidence for pain and fever control. 1, 2, 6

• NSAIDs (ibuprofen, naproxen): Equally effective for moderate to severe symptoms or high fever. 1, 2, 6

• Aspirin: Effective in adults but must be avoided in children due to Reye syndrome risk. 1, 2, 4

• Throat lozenges and warm salt water gargles: May provide symptomatic relief. 1, 2, 6

• Viscous lidocaine and topical anesthetics: Often used in clinical practice but limited data on efficacy. 1

• Corticosteroids are NOT recommended as adjunctive therapy. 4, 6

Critical Pitfalls to Avoid

• Do not prescribe antibiotics without microbiological confirmation in low-risk patients—over 60% of adults with sore throat receive unnecessary antibiotics. 1

• Do not use short courses (<10 days) of standard-dose penicillin or cephalosporins—only azithromycin requires 5 days due to its prolonged tissue half-life. 2, 4

• Do not confuse chronic GAS carriers with active infection—carriers with viral symptoms do not need antibiotics and are unlikely to spread infection or develop complications. 1, 2

• Do not use cephalosporins in patients with immediate/anaphylactic penicillin reactions—the 10% cross-reactivity risk makes this dangerous. 2, 4

• Do not use trimethoprim-sulfamethoxazole (Bactrim) for strep throat—high resistance rates (50%) make it ineffective. 4

Expected Clinical Course

• Antibiotics shorten duration of sore throat by only 1-2 days, with number needed to treat of 6 at 3 days and 21 at 1 week. 1

• The primary benefit of antibiotics is preventing complications (acute rheumatic fever, peritonsillar abscess, further spread) rather than symptom relief. 1

• Typical course of viral sore throat is less than 1 week without treatment. 1

• Symptoms should improve within 48-72 hours—if they worsen or fail to improve, reassessment is warranted. 6