Approach to managing pharyngitis and tonsillitis in patients at high risk of acute rheumatic fever

To determine whether a patient is at high risk of acute rheumatic fever, see here.

Empirical antibiotic therapy for streptococcal pharyngitis and tonsillitis is recommended for all patients at high risk of acute rheumatic fever, even if their clinical features suggest that a viral infection is likely (see Role of clinical features in distinguishing between viral and streptococcal pharyngitis and tonsillitis). This approach is based on expert consensus; it takes into account the difficulty in distinguishing between viral and streptococcal infection based on clinical features, the possible delay in confirming a bacterial diagnosis using a throat swab culture, and a view that the increased risk of acute rheumatic fever and resultant rheumatic heart disease outweighs the risk of harms from potentially unnecessary antibiotic treatment in these patients.

If a patient develops streptococcal pharyngitis or tonsillitis while receiving benzathine benzylpenicillin for prevention of recurrent acute rheumatic fever, seek advice from a specialist with expertise in acute rheumatic fever. Ask the patient about adherence to prophylaxis, and treat the acute infection with antibiotic therapy if it has been more than 7 days since their last dose of benzathine benzylpenicillinNational Heart Foundation of New Zealand, 2019RHDAustralia (ARF/RHD writing group), 2020.

See Antibiotic therapy for streptococcal pharyngitis and tonsillitis for treatment recommendations. If possible, collect a throat swab for culture to confirm S. pyogenes infection before starting antibiotic therapy. Consider stopping antibiotic therapy if the throat swab culture is negative for S. pyogenes and streptococcal infection is not suspected clinically. However, high risk patients are often treated with a single dose of intramuscular benzathine benzylpenicillin and the test turnaround time can be prolonged, so stopping antibiotic therapy in the context of a negative result may not be possible.

Ask patients to return if symptoms (particularly fever) do not improve within a reasonable timeframe (eg 3 to 7 days), or if symptoms worsen or new symptoms develop (eg vomiting, dehydration, rigors) at any timeNational Institute for Clinical Excellence (NICE), 2018.

Patients at high risk of acute rheumatic fever should still be offered symptomatic therapy to treat throat pain and fever.

Children with suspected streptococcal pharyngitis or tonsillitis, or suspected or confirmed viral pharyngitis or tonsillitis, should not attend childcare or school while symptomatic. If S. pyogenes infection is confirmed, exclusion from childcare or school for 24 hours after the first dose of antibiotic therapy or a single dose of intramuscular benzathine benzylpenicillin is generally adequate, but consult local public health guidelinesNational Heart Foundation of New Zealand, 2019.