Tonsillopharyngitis

The current recommended strategy for the management of uncomplicated tonsillopharyngitis in the UK relies on a pragmatic expectant policy i.e. no initial antibiotics are given and the patient is advised to return to their GP if their symptoms are not settling after a few days [15].

Expectant management

The strategy of expectant management is based on a Cochrane review of antibiotics for sore throat [16]. This found that a course of antibiotics has minimal effect on the course of the illness, shortening it by approximately 16 hours.

Another study found that an antibiotic prescription increases the chance of a patient with a sore throat returning in the future for antibiotics [17]. Despite this evidence, antibiotic prescribing rates remain high. Patient expectation is often quoted as the main reason for this but, in a study conducted in 10 EDs in the USA, patient satisfaction rates were not altered by the decision to prescribe antibiotics for upper respiratory tract infections [18].

Learning bite

Treating an uncomplicated sore throat with antibiotics has little effect on the clinical course of the illness and may encourage patients to return in the future when a similar problem arises. It also increases risk of anti-microbial resistance or side effects.

Antibiotic Prescription

NICE currently advise to consider antibiotic prescription if the FeverPAIN score is 4 or 5, or CENTOR score is 3 or 4, and a rapid streptococcal antigen test is pending or not available. If the FeverPAIN is 2 or 3 then you should consider a delayed antibiotic prescription.

 The threshold is lower if the patient is at risk of rheumatic fever or are vulnerable. Antibiotics should not be withheld if the person has very severe symptoms and there is concern about their clinical condition.

Learning Bite

During Covid-19, RCPCH have recommended only examining children’s’ throats if necessary. If not, they recommend assuming a score 2 in lieu of examination [23].

Antibiotic choice

Phenoxymethylpenicillin QDS for 10 days is the first line choice antibiotic. If the patient is penicillin allergic then recommendation is clarithromycin, or erythromycin if they are also pregnant.

Phenoxymethylpenicillin is normally prescribed as a four times daily regime although, in a meta-analysis, similar cure rates were found for twice daily dosing [19] with consequent better compliance rates.

Amoxicillin and other Ampicillin antibiotics should be avoided in sore throat due to the possibility of causing maculopapular exanthems in patients with infectious mononucleosis.

Other treatment

Simple analgesia including paracetamol, non-steroidal anti-inflammatories and topical local anaesthetic agents (e.g. Benzydramine spray/mouthwash) are effective in patients with a sore throat and may have a greater positive effect than antibiotics alone.

Steroids such as Dexamethasone are frequently used in hospital if the patient is unable to swallow due to severe pain or has stridor.