Approach to managing pharyngitis and tonsillitis in patients not at high risk of acute rheumatic fever

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

For patients who are not at high risk of acute rheumatic fever with clinical features that strongly suggest viral pharyngitis or tonsillitis, use symptomatic therapy alone. Explain to the patient or carer that antibiotic therapy is of no benefit, and that this is a self-limiting condition and symptoms usually resolve within 7 days. Ask patients to return if symptoms worsen or if new symptoms develop (eg vomiting, dehydration, rigors) at any time, or if symptoms do not improve (particularly fever) within a reasonable timeframe (eg 3 to 7 days)National Institute for Clinical Excellence (NICE), 2018.

Streptococcal pharyngitis and tonsillitis are usually self-limiting, and antibiotics only shorten the duration of symptoms by less than 1 day; at day 7 there is no difference in improvement between patients treated with and without antibioticsSpinks, 2013. This small benefit of antibiotic therapy must be balanced against the potential harms (eg diarrhoea, rash or more serious hypersensitivity reactions, bacterial resistance). There is insufficient evidence that antibiotics prevent the complication of poststreptococcal glomerulonephritis and routine treatment of streptococcal pharyngitis and tonsillitis is not recommended for this purposeShulman, 2012.

For patients who are not at high risk of acute rheumatic fever with clinical features that suggest streptococcal pharyngitis or tonsillitis is likely, consider empirical antibiotic therapy if:

• symptoms are severe (eg severe throat pain, dysphagia), to reduce the severity and duration of symptoms, or
• the patient has a scarlet fever–type rash, to reduce the infectious period and risk of transmission of toxin-producing strains of S. pyogenes—refer to local public health guidelines.

All other patients who are not at high risk of acute rheumatic fever with suspected streptococcal pharyngitis or tonsillitis can be treated with symptomatic therapy alone. 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.

Many patients have an expectation of treatment with antibiotics. Effective communication with the patient or carer about the limited role of antibiotics in streptococcal pharyngitis and tonsillitis is essential. The discussion should address misconceptions about the effectiveness of antibiotic therapy and the expectation of an antibiotic prescription. Shared decision making, which involves a discussion of the evidence for the potential benefits and harms of therapy, provides a useful template for these discussions.

If antibiotic therapy is being considered, collect a throat swab for culture, if possible. Base the decision to use or continue antibiotic therapy on culture results and the patient’s clinical progress (see Role of investigations in viral and streptococcal pharyngitis and tonsillitis). Antibiotic therapy can be considered for patients with confirmed S. pyogenes on throat swab culture who have ongoing symptoms of pharyngitis or tonsillitis.

If a decision is made to use antibiotic therapy, see Antibiotic therapy for streptococcal pharyngitis and tonsillitis for treatment recommendations.

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.