What is the recommended management of acute tonsillopharyngitis, including assessment of bacterial risk and appropriate antibiotic therapy?

Management of Acute Tonsillopharyngitis

Test all patients with suspected bacterial pharyngitis using rapid antigen detection testing (RADT) or throat culture, and prescribe antibiotics only for confirmed Group A Streptococcus (GAS) infection—penicillin V or amoxicillin for 10 days remains first-line therapy. 1

Clinical Assessment to Determine Testing Need

Features Favoring GAS Infection (Test These Patients)

• Sudden onset of severe sore throat with fever ≥101°F (38.3°C) strongly suggests bacterial etiology. 1
• Tonsillopharyngeal erythema with or without patchy discrete exudates increases likelihood of GAS. 1, 2
• Tender, enlarged anterior cervical lymph nodes are characteristic of streptococcal infection. 1
• Absence of viral symptoms (no cough, rhinorrhea, hoarseness, or conjunctivitis) favors bacterial cause. 1
• Additional supportive findings include headache, nausea, vomiting, abdominal pain, palatal petechiae, or scarlatiniform rash. 1
• Peak age 5–15 years and winter/early spring presentation increase pre-test probability. 1

Features Favoring Viral Etiology (Do NOT Test)

• Presence of cough, rhinorrhea, hoarseness, or conjunctivitis argues strongly against bacterial infection and testing is not recommended. 1, 2
• Discrete oral ulcers or ulcerative stomatitis indicate viral cause. 2, 3
• Diarrhea is more commonly associated with viral pharyngitis. 1

Critical caveat: Clinical features alone cannot reliably distinguish viral from bacterial pharyngitis—even experienced clinicians achieve only 50–75% accuracy—making microbiological confirmation mandatory before prescribing antibiotics. 1, 2

Diagnostic Testing Strategy

Children and Adolescents (≥3 Years)

• Perform RADT first; a positive result is diagnostic and warrants immediate treatment. 1, 2
• A negative RADT must be followed by throat culture because RADT sensitivity is only 80–90%, missing 10–20% of true GAS infections. 1, 2
• Do not test children <3 years unless specific risk factors exist (e.g., confirmed GAS contact), as GAS pharyngitis and rheumatic fever are rare in this age group. 1, 2

Adults

• Perform RADT; a positive result confirms GAS and requires treatment. 1, 2
• A negative RADT is sufficient to rule out GAS—backup throat culture is not required due to low rheumatic fever risk and high RADT specificity (90–96%) in adults. 1, 2

When NOT to Test

• Do not test patients with obvious viral features (cough, rhinorrhea, conjunctivitis, oral ulcers)—positive results likely represent asymptomatic carriage rather than true infection. 1, 2, 3
• Do not test or treat asymptomatic household contacts—up to one-third may carry GAS, but prophylactic antibiotics do not reduce subsequent infection rates. 2

Antibiotic Treatment for Confirmed GAS Pharyngitis

First-Line Therapy (No Penicillin Allergy)

• Penicillin V: 250 mg twice or three times daily (children) or 250 mg four times daily or 500 mg twice daily (adolescents/adults) for 10 days. 1
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days—preferred in young children for better palatability. 1, 2
• Benzathine penicillin G (intramuscular): Single dose of 600,000 units (<27 kg) or 1,200,000 units (≥27 kg) when adherence to oral therapy is uncertain. 1, 2

Rationale: Penicillin and amoxicillin offer proven efficacy, zero GAS resistance, narrow spectrum, excellent safety, and low cost. 1, 2

Penicillin-Allergic Patients (Non-Anaphylactic)

• Narrow-spectrum cephalosporin (cephalexin 20 mg/kg twice daily [maximum 500 mg/dose] or cefadroxil 30 mg/kg once daily [maximum 1 g]) for 10 days. 1, 2
• Avoid broad-spectrum cephalosporins (cefdinir, cefixime, cefpodoxime) when narrow-spectrum options are available—they are more expensive and promote resistance. 2

True Penicillin Allergy or Anaphylaxis

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg/dose) for 10 days—excellent option with only ~1% GAS resistance in the United States. 1, 2
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days—use with caution due to 5–8% macrolide resistance rates in most U.S. areas. 1, 2
• Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg/dose) for 10 days—similar resistance concerns as azithromycin. 1

Critical point: Complete the full 10-day course (except azithromycin 5 days) to ensure bacterial eradication and prevent acute rheumatic fever. 1, 2

Management of Viral Pharyngitis (Negative Testing)

• Do not prescribe antibiotics—more than 60% of adults with sore throat inappropriately receive antibiotics despite viral etiology. 1
• Provide symptomatic care only: analgesics (acetaminophen, NSAIDs, throat lozenges), adequate hydration, warm saline gargles, and topical anesthetics. 1
• Avoid aspirin in children due to Reye syndrome risk. 2
• Reassure patients that typical sore throat duration is <1 week and antibiotics provide minimal benefit (number needed to treat = 6 at 3 days, 21 at 1 week). 1

Recognition of Treatment Failure and Complications

When to Reassess (48–72 Hours)

• If no clinical improvement within 48–72 hours of appropriate antibiotic therapy, reassess to confirm GAS diagnosis and exclude other causes. 1
• Consider changing antibiotics if GAS is confirmed but patient fails initial therapy. 1
• Evaluate for suppurative complications (peritonsillar abscess, cervical lymphadenitis, mastoiditis) if symptoms worsen or persist beyond 3 days. 1, 4

Red-Flag Features Requiring Urgent Evaluation

• Difficulty swallowing, drooling, neck tenderness, or swelling suggest peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome. 1
• Severe pharyngitis in adolescents/young adults warrants vigilance for Fusobacterium necrophorum infection and Lemierre syndrome—a rare but life-threatening condition. 1

Common Pitfalls to Avoid

• Do not treat based on clinical impression alone—this leads to unnecessary antibiotic use in 50–70% of cases because viral causes predominate. 1
• Do not assume all exudative pharyngitis is bacterial—viruses (adenovirus, EBV) frequently produce exudates. 1
• Do not perform routine post-treatment testing in asymptomatic patients—positive results usually reflect carrier status rather than treatment failure. 1, 2
• Do not label patients as penicillin-allergic based solely on benign maculopapular rash during viral illness—more than 90% of reported penicillin allergies are not true allergies. 2
• Do not shorten antibiotic duration below 10 days (except azithromycin)—this compromises bacterial eradication and rheumatic fever prevention. 1, 2

Outcomes Prioritized by This Approach

• Prevention of acute rheumatic fever—the primary justification for antibiotic treatment of GAS pharyngitis. 1
• Prevention of suppurative complications (peritonsillar abscess, cervical lymphadenitis, mastoiditis). 1
• Reduction in symptom duration by 1–2 days (modest benefit). 1
• Decreased transmission to close contacts. 1
• Minimization of inappropriate antibiotic use and associated adverse effects, costs, and resistance. 1