Kijabe OPD Guidelines
Sore throat / tonsillitis / pharyngitis
Key facts
• One of the most frequent reasons for seeking healthcare and one of the commonest reasons for using antibiotics
worldwide, although most are viral in origin.
• 85% resolve within 7 days (regardless of whether viral or bacterial) and antibiotics reduce symptom duration by just 16
hours; tonsillitis is unusual in age<3y and ≥45 years
• Use the Centor score to identify patients who may benefit most from antibiotics
• Possible complications of tonsillitis: otitis media, peritonsillar abscess, obstructive sleep apnoea,
scarlet fever, acute rheumatic fever, glomerulonephritis
Refer to casualty or discuss with
General assessment for danger signs
consultant if signs of severe
and as history indicates
illness
Examination of throat/soft palate and neck
- Ensure a good view using a bright light +/- tongue depressor
- In children, make sure that parent/carer is holding the child in a
good position if young, and also check ears
Suspicion of peritonsillar abscess (quinsy)? Needs ENT review for drainage
(bulging soft palate & uvula deviation; YES Discuss with consultant
higher risk teenagers/young adults)
NO
Age <3y Age >3
Clinical assessment, tonsillitis unusual at
this age, usually viral cause; if rash, assess
for scarlet fever (see below). CENTOR SCORE (Modified/McIsaac)
Discuss with consultant if in doubt use in age ≥3y, with recent onset (3d) of sore throat
Score
Fever 1
Tonsillar swelling or exudate 1
Absent cough 1
Tender/swollen anterior cervical lymph nodes 1
Age 3-14 years 1
Discuss with consultant Age 15-44 years 0
• Signs of severe illness Age ≥45 years -1
• Suspicion of peritonsillar abscess
• Patient unable to swallow at all
• Persistent sore throat Total Risk of Strep Need for antibiotics?
score Infection (see page 2 for treatment details)
• Tonsillitis and age >45 years
0 1-2.5%
• Unilateral presentation 1 5-10% No antibiotics
• Suspicion of malignancy 2 11-17%
• If considering referral for tonsillectomy 3 28-35% Immediate antibiotics if severe symptoms
≥4 51-53% or, if less severe, consider a delayed
prescription or arrange review in 48h
- Blood tests not required to help decide whether to prescribe antibiotics or not in
cases of sore throat – use the Centor score. If in doubt speak to consultant.
- If sore throat + rash, consider scarlet fever (see below)
Treatment
1. Explain diagnosis and likely time-frame (most better within 7d)
2. Self-care advice – regular analgesia, drinks - honey & lemon (not if age <1y), teas, cold drinks/ice, throat lozenges
3. Antibiotics? depending on Centor Score (see antibiotic choice on page 2); if antibiotics not indicated, explain why & possible side-effects
4. Safety netting – advise to return if: danger signs (e.g. inability to drink, unable to swallow saliva, drowsiness, confusion, high fever not
responding to simple measures, swelling, difficulty/fast breathing); very worried; ongoing symptoms despite treatment
5. Corticosteroids? - Can consider a single dose in patients with severe pain, especially if struggling with oral intake. Do not give routinely
(adults: 10 mg dexamethasone or 60mg prednisolone)
Kijabe OPD Guidelines
How to do a ‘delayed prescription of antibiotics’
Write a paper prescription (add expiry date 5-10 days time), explain
that antibiotics are not required at present and that we expect the
infection to get better on its own, but incase symptoms
continue/worsen, they can fill the prescription at a pharmacy after a
predetermined period (e.g. 2-3d)
CHOICE OF ANTIBIOTICS IN TONSILLITIS
DRUG DOSE DURATION
First line: Benzathine Penicillin <27kg: 0.6 million units IM as a single dose 1 dose
>27kg: 1.2 million units IM as a single dose
OR
Penicillin V (250mg tablets)* Child 1-11m: 62.5mg QDS or 125mg BD 10 days (to increase
Child 1-5y: 125mg QDS or 250mg BD likelihood of Strep
Child 6-11y: 250mg QDS or 500mg BD eradication)
Adult/child>12y: 500mg QDS or 1g BD
If children unable to take penicillin 25mg/kg 12 hourly (maximum 1.5g) 10 days
tablets (first choice): amoxicillin syrup
In penicillin Clarithromycin (500mg tablets) 12 to 19 kg: 125 mg BD 10 days
allergy and 2nd 20 to 29 kg: 187.5 mg BD
line: 30 to 40 kg: 250 mg BD
Child ≥ 12yrs and adults: 250mg BD
Erythromycin – if pregnant (preferred Child 1m-7y: 40mg/kg divided BD 10 days
to clarithromycin) or syrup for children Adult and child > 8yrs: 500 – 1000mg BD
unable to take tablets
* Penicillin V is better than alternatives for treating Group A Strep as it is very effective but also narrow spectrum, which is better for avoiding AMR
Scarlet Fever
• Disease resulting from exotoxin produced by Group A beta-haemolytic strep; can lead to invasive disease
• Commonest in children aged 2-8y
• Presents with sore throat, fever and a rash; headache, fatigue, vomiting, abdo pain are common.
• The rash: appears on second day, neck and chest first then spreads, coarse texture like sandpaper, (later desquamation)
• On examination: strawberry tongue, cervical lymphadenopathy, flushed face (perioral pallor), pharyngitis with
haemorrhagic spots on palate
• Check for features of systemic disease
• Treat with antibiotics as above, for a full 10 days Referral for tonsillectomy
of treatment Two indications for tonsillectomy: recurrent infection and
• Observe if immunocomprosmied as increased risk sleep disordered breathing (sleep apnoea)
of invasive infection In recurrent tonsillitis, consider tonsillectomy if:
- 3 infections per year for 3 consecutive years, or
- 5 infections per year for 2 consecutive years, or
- 7 infections in a one year period
No need to send to ENT during the acute infection, treat as
above and arrange OPD appointment.
References
WHO Essential Medicines https://list.essentialmeds.org/recommendations/527
UpToDate accessed 6/1/23; BJGP 2017;67:e634 ; BMJ 2017;358:j4090
Worldwide comparison of treatment guidelines for sore throat https://doi.org/10.1111/ijcp.13879
Reviewed and approved by AIC Kijabe Hospital AMS Committee November 2023. Version 2; 1/23
