What is the appropriate treatment for an adult with exudative tonsillopharyngitis?

Treatment of Exudative Tonsillopharyngitis in Adults

Adults with exudative tonsillopharyngitis should receive antibiotics only after laboratory confirmation of Group A Streptococcus (GAS) infection, with penicillin or amoxicillin for 10 days as first-line therapy. 1, 2

Confirm the Diagnosis Before Treating

The presence of tonsillar exudates does not reliably distinguish bacterial from viral pharyngitis—exudates occur commonly with viral infections including adenovirus, Epstein-Barr virus, and other pathogens. 1, 3

Use the modified Centor criteria to determine who needs testing:

• Fever by history
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough 1, 2

Testing algorithm:

• Fewer than 3 Centor criteria: Do not test; withhold antibiotics and provide symptomatic care only 1, 2
• 3 or 4 Centor criteria: Perform rapid antigen detection test (RADT) 1, 2
• Negative RADT in adults: No backup throat culture needed—this is sufficient to rule out GAS 1, 2, 4
• Positive RADT: Treat with antibiotics 2

Do not test or treat when viral features are present: cough, nasal congestion, conjunctivitis, hoarseness, diarrhea, or oropharyngeal ulcers/vesicles strongly indicate viral etiology. 1, 5

First-Line Antibiotic Therapy for Confirmed GAS

Penicillin remains the drug of choice due to proven efficacy, narrow spectrum, safety, zero resistance over five decades, and low cost. 2, 5

Specific regimens:

• Penicillin V: 500 mg twice daily for 10 days 2
• Amoxicillin: 500 mg twice daily for 10 days 2, 6
• Benzathine penicillin G (IM): 1.2 million units as a single dose for patients with compliance concerns 2

The 10-day duration is mandatory to ensure eradication of GAS from the pharynx and prevent acute rheumatic fever. 1, 2 Shorter courses cannot be recommended despite newer agents showing efficacy, as comprehensive validation is lacking. 2

Penicillin-Allergic Patients

Non-anaphylactic penicillin allergy:

• First-generation cephalosporin (e.g., cephalexin 500 mg twice daily) for 10 days 2

Anaphylactic or immediate-type hypersensitivity:

• Clindamycin for 10 days 2
• Azithromycin 500 mg once daily for 5 days (total dose 2.5 g) 2
• Clarithromycin for 10 days 2

Azithromycin is explicitly not a first-line agent and should be reserved only for documented penicillin allergy. 5 Macrolides have inferior efficacy compared to penicillin and promote resistance. 1

Symptomatic Management

Offer all patients analgesics regardless of whether antibiotics are prescribed:

• Acetaminophen, NSAIDs (ibuprofen), or throat lozenges for moderate to severe symptoms 1, 2, 5

Do not use corticosteroids for routine treatment of streptococcal pharyngitis. 2

Clinical Benefits and Limitations

Antibiotics provide modest symptomatic benefit—they shorten sore throat duration by only 1–2 days, with a number needed to treat of 6 at day 3 and 21 at one week. 1, 2

The primary justification for treating confirmed GAS is prevention of complications:

• Acute rheumatic fever (can be prevented if treatment starts within 9 days of symptom onset) 2
• Peritonsillar abscess 1, 2
• Spread during outbreaks 1, 2

Antibiotics do not prevent post-streptococcal glomerulonephritis. 1

When NOT to Treat

Do not treat chronic GAS carriers who have repeated positive tests during viral infections—they are at low risk for complications and transmission. 1, 2

Do not perform routine post-treatment testing in asymptomatic patients; positive tests likely reflect carrier status rather than treatment failure. 2

Do not test or treat asymptomatic household contacts—up to one-third may be carriers, but prophylactic treatment does not reduce subsequent infection rates. 2

Red Flags Requiring Urgent Evaluation

Reevaluate immediately if the patient develops:

• Difficulty swallowing or drooling
• Neck tenderness or swelling
• Unilateral tonsillar bulge with uvular deviation (peritonsillar abscess)
• Worsening symptoms after 48–72 hours of appropriate antibiotics 1, 5

Be vigilant for Lemierre syndrome in adolescents and young adults with severe pharyngitis—this rare, life-threatening condition requires urgent diagnosis and treatment. 1, 2

Common Pitfalls to Avoid

Over 60% of adults with sore throat receive unnecessary antibiotic prescriptions despite most cases being viral. 1, 5 Exudates and white patches occur with both viral and bacterial infections and cannot be used to diagnose GAS clinically. 1, 3

Do not prescribe antibiotics based on clinical appearance alone—laboratory confirmation is mandatory. 1, 2, 5

Do not switch antibiotics without microbiological indication—this increases adverse effects without clinical benefit. 3