Tonsillitis and Peritonsillar Abscess Guidelines

Updated: Mar 19, 2018
  • Author: Udayan K Shah, MD, FACS, FAAP; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Guidelines Summary

In 2012, the Infectious Diseases Society of America (IDSA) released updated guidelines for the diagnosis and management of group A streptococcal (GAS) pharyngitis. Recommendations for diagnosis and testing are summarized as follows [17] :

  • Testing for GAS pharyngitis by rapid antigen detection test (RADT) and/or culture should be performed to distinguish between GAS and viral pharyngitis
  • In children and adolescents, negative RADT results should be backed up by a throat culture; positive results are highly specific and do not require a backup culture
  • In adults, routine use of backup throat cultures for those with a negative RADT is not necessary because the risk of subsequent acute rheumatic fever is low in adults with acute pharyngitis
  • Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis
  • In general, testing for GAS pharyngitis is not recommended for children or adults with a clinical presentation that strongly suggests a viral etiology (eg, cough, rhinorrhea, hoarseness, oral ulcers)
  • Acute rheumatic fever is rare in children under age 3 years, and the incidence and classic presentation of streptococcal pharyngitis are uncommon in this age group; thus, testing for GAS pharyngitis is not indicated for children under age 3 years; however, children under age 3 years who have other risk factors, such as an older sibling with GAS infection, may be considered for testing
  • Diagnostic testing or treatment of asymptomatic close contacts of patients with acute streptococcal pharyngitis is not routinely recommended

ISDA guideline recommendations for treatment include the following [17] :

  • Patients with confirmed GAS pharyngitis should be treated for a duration likely to eradicate GAS from the pharynx (usually 10 days) with an appropriate narrow-spectrum antibiotic
  • Penicillin or amoxicillin is the drug of choice for those without a contraindication
  • Alternative agents for penicillin-allergic individuals include a first-generation cephalosporin, clindamycin, or clarithromycin for 10 days, or azithromycin for 5 days 
  • An analgesic such as acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) may be considered as an adjunct to an appropriate antibiotic for treatment of moderate to severe symptoms or control of high fever; aspirin should be avoided in children
  • Adjunctive therapy with a corticosteroid is not recommended
  • In patients with recurrent episodes of pharyngitis, consider the possibility that they are a chronic pharyngeal GAS carrier who is experiencing repeated viral infections
  • Efforts to identify GAS carriers are not justified because they have a low risk of transmitting GAS pharyngitis to their close contacts and little or no risk for the development of acute rheumatic fever
  • Tonsillectomy is not recommended to reduce the frequency of GAS pharyngitis

In joint guidelines for appropriate antibiotic use for acute respiratory tract infection in adults, published in 2016, the American College of Physicians (ACP) and the Centers for Disease Control and Prevention (CDC) note that adult patients may be assured that antibiotics are usually not needed for a sore throat because they do little to alleviate symptoms and may have adverse effects. [34]

The 2011 clinical practice guidelines on tonsillectomy in children released by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) offers the following recommendations [19] :

  • If there have been fewer than seven episodes of recurrent throat infection in the past year or fewer than five episodes per year in the past 2 years or fewer than three episodes per year in the past 3 years, watchful waiting is preferred over tonsillectomy
  • Tonsillectomy is indicated for recurrent throat infection of at least seven episodes in the past year or at least five episodes per year for 2 years or at least three episodes per year for 3 years with documentation of one or more of the following: temperature above 38.3°C, cervical adenopathy, tonsillar exudate, and/or positive test for Group A β-hemolytic streptococcus (GABHS)
  • Tonsillectomy may be considered in children who do not meet the above criteria but have multiple antibiotic allergies/intolerances, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or a history of peritonsillar abscess