Pharyngitis and Tonsillitis

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This is an infection of the throat and tonsils. Most sore throats are due  to viral infections and should NOT be treated with antibiotics as they subside within 3 to 5 days.  However, it is important to diagnose streptococcal pharyngitis since it may give rise to abscesses in the throat (retropharyngeal and peritonsillar abscess) as well as complications that involve organs like the kidneys and the heart. Streptococcal throat infections require treatment with antibiotics in order to reduce the complications noted above.

Cause

  • Viruses
  • Heamolytic streptococcus
  • Haemophilus influenza
  • Other gram positive bacteria 

Symptoms

  • Fever
  • Difficulty in swallowing
  • Sore throat
  • Runny nose 
  • Cough

Signs

  • Reddened throat
  • Enlarged and reddened tonsils 
  • Sustained high grade fever
  • Palpable tonsillar lymph glands (streptococcal pharyngitis) 
  • Runny nose (suggests viral)
  • Cough (suggests viral)
  • Red eyes (suggests viral)
  • Whitish exudate at the back of the throat as well as whitish tonsillar exudate
  • Scarlet fever rash

Investigations

  • FBC 
  • Monospot test 
  • Throat swab for culture and sensitivity

TreatmentTreatment Objectives

  • To relieve symptoms
  • To recognise and treat streptococcal throat infection 
  • To relieve pain

Non-pharmacological treatment

  • Warm, salty water gargles

Pharmacological treatment 

For pain relief

1st Line Treatment

Evidence Rating: [A]

  • Paracetamol, oral, 

Adults 

500 mg-1 g 6-8 hourly 

Children

6-12 years; 250-500 mg 6-8 hourly

1-5 years; 120-250 mg 6-8 hourly

3 months-1 year; 60-120 mg 6-8 hourly

Or

  • Ibuprofen, oral,

Adults 

200-400 mg 8 hourly

Children

7-12 year; 7.5-10 mg/kg 6-8 hourly (max. 30 mg/kg or 600 mg per day)

4-7 years; 7.5-10 mg/kg 8 hourly (max. 30 mg/kg or 450 mg per day)

For treating the infection

1st Line Treatment 

Evidence Rating: [A]

  • Amoxicillin, oral, 

Adults 

500 mg 8 hourly for 10 days 

Children

6-12 years; 250 mg 8 hourly for 10 days
1-5 years; 125 mg 8 hourly for 10 days
< 1 year; 62.5 mg 8 hourly for 10 days

Or

  • Amoxicillin + Clavulanic Acid, oral,

Adults 

1 gram 12 hourly for 10 days 

Children

> 12 years; One 500/125mg strength tablet, 12 hourly for 10 days

6-12 years; 5ml of 400/57mg suspension 12 hourly (5ml of 250/62mg suspension 8 hourly for 10 days; dose doubled in severe infection)  

1-6 years; 5 ml of 200/28.5 mg suspension 12 hourly for 10 days; dose doubled in severe infection

1 month-1 year; 2.5 ml of 200/28.5 mg suspension 12 hourly for 10 days; dose doubled in severe infection

Neonate;

2.5 ml of 200/28.5 mg suspension 12 hourly for 10 days; dose doubled in severe infection

Or

  • Amoxicillin + Clavulanic Acid, IV,

Adults

600 mg-1.2 g 12 hourly for 10 days

Children 

1-12 years; 15 mg/kg 12 hourly for 10 days 

Or

  • Crystalline Penicillin, IV,

Adults

2-4 MU 6 hourly for 10 days

Children 

> 12 years; 2-4 MU 6 hourly for 10 days

1-12 years; 0.6-1.2 MU (25 mg/kg) 6 hourly for 10 days

Note: Do not give co-trimoxazole for acute streptococcal throat infections 

2nd Line Treatment

Evidence Rating: [B]

  • Cefuroxime, oral,

Adult 

250 mg 12 hourly for 10 days

Children 

> 12 years 250 mg 12 hourly for 10 days

3 months-12 years; 10 mg/kg 12 hourly for 10 days 

Or

  • Cefuroxime, IV,

Adult 

750 mg 8 hourly for 10 days

Children 

> 12 years; 750 mg 8 hourly for 10 days

3 months-12 years; 25-50 mg/kg 8 hourly for 10 days 

For treating the infection in patients allergic to penicillin

  • Erythromycin, oral,

Adults

500 mg 6 hourly for 10 days 

Children

2-8 years; 250 mg 6 hourly for 10 days

1 month-2 years; 125 mg 6 hourly for 10 days

Neonates;

12.5 mg/kg 6 hourly

Or

  • Azithromycin, oral,

Adults 

500 mg daily for 3 days

Children

> 6 months; 10 mg/kg daily for 3 days

Referral Criteria

Refer patients with recurrent tonsillitis, retropharyngeal and peritonsillar abscess to an ENT specialist.