How should I evaluate and manage a patient with sore throat, fever, erythematous tonsils with exudates, and tender cervical lymphadenopathy?

Evaluation and Management of Acute Tonsillitis with Exudates

You must obtain microbiological confirmation with either a rapid antigen detection test (RADT) or throat culture before prescribing antibiotics, as clinical features alone—even with classic findings of fever, exudates, and tender lymph nodes—cannot reliably differentiate bacterial from viral pharyngitis. 1, 2

Initial Clinical Assessment

Features Suggesting Group A Streptococcal (GAS) Infection

Your patient's presentation includes several features consistent with bacterial pharyngitis:

• Sudden onset sore throat with fever 1, 3
• Tonsillopharyngeal erythema with exudates 2, 3
• Tender, enlarged anterior cervical lymph nodes 1, 2
• Absence of viral features (no cough, rhinorrhea, conjunctivitis, or hoarseness) 1

Apply Modified Centor Criteria

Calculate the score (1 point each):

• Fever by history: 1 point
• Tonsillar exudates: 1 point
• Tender anterior cervical adenopathy: 1 point
• Absence of cough: 1 point

With a score of 4/4, this patient requires microbiological testing 1

Critical Diagnostic Principle

Even with all four Centor criteria present, only 35-50% of cases are actually GAS-positive, which is why testing is mandatory. 3 The signs and symptoms of streptococcal and viral pharyngitis overlap too broadly for diagnosis on clinical grounds alone, even by experienced physicians. 1

Diagnostic Testing Strategy

Recommended Approach

• Perform RADT immediately at point-of-care 1, 3
• RADT has 90-96% specificity and 79-88% sensitivity 3
• If RADT is positive: Diagnosis confirmed, proceed to treatment 3
• If RADT is negative in children/adolescents: Confirm with throat culture (gold standard) 3
• If RADT is negative in adults: Throat culture confirmation is optional, as adults have lower GAS prevalence (5-10% vs 15-30% in children) 1

Do NOT Rely on Laboratory Values Alone

• While bacterial infections may show WBC >12,000/mm³ with neutrophilia, and viral infections typically show WBC <10,000/mm³ with lymphocytosis, these findings have poor sensitivity and specificity and should not guide antibiotic decisions 3

Treatment Based on Test Results

If GAS-Positive: First-Line Antibiotic Therapy

Penicillin remains the drug of choice due to proven efficacy, safety, narrow spectrum, low cost, and complete absence of resistance. 3

Treatment options:

• Penicillin V: 250 mg PO TID (or 500 mg BID) for 10 days in adults 1, 3
• Amoxicillin: Alternative option, especially in younger children, but avoid in adolescents/young adults if infectious mononucleosis (EBV) is possible due to severe rash risk 3
• Intramuscular benzathine penicillin G: Single dose option if compliance is a concern 1

The full 10-day course is essential for bacterial eradication and prevention of acute rheumatic fever. 3

For Penicillin-Allergic Patients

If non-anaphylactic penicillin allergy:

• Narrow-spectrum cephalosporins (cefadroxil or cephalexin) for 10 days 3

If true anaphylactic penicillin allergy:

• Clindamycin is the preferred alternative with only ~1% GAS resistance in the United States 3
• Macrolides/azalides (azithromycin 5 days, clarithromycin, or erythromycin) are reasonable but use with caution due to 5-8% macrolide resistance rates 3

Avoid broad-spectrum cephalosporins (cefdinir, cefixime, cefpodoxime), fluoroquinolones, tetracyclines, and sulfonamides. 3

If GAS-Negative: Supportive Care Only

Do not prescribe antibiotics for viral pharyngitis, as they provide no benefit and contribute to antibiotic resistance. 1, 4

Symptomatic management includes:

• Acetaminophen or NSAIDs for throat pain, fever, and headache 4, 3
• Throat lozenges for temporary relief 4
• Warm salt water gargles 4
• Adequate hydration 4
• Rest 3

Key Outcomes Prioritized by Treatment

The goals of appropriate management are to prevent serious complications that affect morbidity and mortality:

1. Prevention of acute rheumatic fever (primary concern) 1
2. Prevention of suppurative complications (peritonsillar abscess, cervical lymphadenitis, mastoiditis) 1
3. Symptom resolution and reduced infectivity 1
4. Avoidance of unnecessary antibiotic adverse effects 1

Red Flags Requiring Urgent Evaluation

Return immediately or refer urgently if the patient develops:

• Difficulty swallowing, drooling, neck tenderness, or neck swelling (suggests peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome) 1, 4
• Severe pharyngitis in adolescents/young adults (consider Fusobacterium necrophorum and Lemierre syndrome) 1, 4
• Symptoms persisting >10 days without improvement 4
• High fever persisting >4 days 4

Common Pitfalls to Avoid

• Never prescribe antibiotics based on clinical appearance alone without microbiological confirmation 1, 3
• Do not test or treat asymptomatic household contacts 1
• Do not perform repeat testing after successful treatment completion 1
• Recognize that patients may be GAS carriers with concurrent viral pharyngitis (positive test but viral symptoms) 3
• Do not use aspirin in children due to Reye syndrome risk 3