Clinical definition:
Acute inflammation of the pharyngeal wall and tonsils commonly caused by viral pathogens including respiratory viruses and Epstein-Barr virus. Common bacterial etiologies include group A beta-haemolytic Streptococci (S. pyogenes). Common symptoms include sore throat and fever.
| Child & Adolescent | |||
| Preferred antibiotic choice | |||
| Drug | Formulation | Dosage | Duration |
| Amoxicillin (PO)A | Powder for oral liquid: 125 mg (as trihydrate)/ 5 mL; 250 mg (as trihydrate)/5 mL; Solid oral dosage form: 250 mg; 500 mg (as trihydrate). | 50 mg/kg once daily, maximum dose 2 g | 10 days |
| Alternative antibiotic choice(s) | |||
| Benzathine benzylpenicillin (IM)B | Powder for injection: 900 mg benzylpenicillin (=1.2 million units) in 5 mL vial; 1.44 g benzylpenicillin (=2.4 million units) in 5 mL vial | By weight: o <27 kg: 600 000 units (375 mg) as a single dose o 27 kg and above: 1.2 million units (750 mg) as a single dose | Single dose |
| In case of confirmed drug allergy or medical contraindication | |||
| Azithromycin (PO)C | Oral liquid: 200 mg/5 mL. Capsule: 250 mg; 500 mg (anhydrous). | 10 mg/kg once daily, maximum dose 500 mg daily | 5 days |
A. If a patient cannot tolerate oral antibiotics (e.g. persistent vomiting), IV or IM antibiotics may be considered:
- Ampicillin (25 mg/kg/dose 6 hourly, Maximum dose: 500 mg 6 hourly), or
- Ceftriaxone (50 mg/kg/dose once daily, Maximum dose: 1 g daily)
B. Painful IM administration of benzathine benzylpenicillin may be reduced by dissolving benzathine benzylpenicillin 1.2 million units in 3.2 mL lidocaine 1% without adrenaline (epinephrine) and bringing the preparation to room temperature before injection.
C. Significant rates of resistance of Group A Streptococcus strains to macrolides (azithromycin) and azalides (clarithromycin) have been reported in many parts of the world. If patient fails treatment with a macrolide or azalide, consider ceftriaxone or refer to a specialist.
Principles of Stewardship:
- Clinical features that suggest a viral rather than a bacterial cause of pharyngotonsillitis include runny nose, hoarse voice or cry, cough, conjunctivitis, discrete oral ulcerative lesions, and diarrhoea. In these cases, avoid antibiotic use.
- Children less than 3 years of age should not receive antibiotics as part of treatment for pharyngotonsillitis as they are not at significant risk for acute rheumatic fever.