Diagnosis and Management of Acute
Tonsillopharyngitis in Family Practice
Daisy M Medina, MD, FPAFP, Noel M. Espallardo, MD, MSc, FPAFP, Ma. Teresa Tricia G. Bautista, MD,
FPAFP, Joan Mae Oliveros, MD, FPAFP, Ma. Rosario Bernardo-Lazaro, MD, MBAH, FPAFP, Jane Eflyn L.
Lardizabal-Bunyi MD, DFM, PAFP
Abstract
Background
Acute tonsillopharyngitis is a common reason for consult in the primary care setting. Although most
cases are viral in etiology, more than half of patients with acute tonsillopharyngitis still receive
antibiotic therapy for group A beta-hemolytic streptococcal infection. Streptococcal throat infection
may lead uncommonly to suppurative complications like peritonsillar abscess and non-suppurative
complications like acute rheumatic fever. It is with this consideration that streptococcal throat infection
must be distinguished from viral infections. Clinical practice guidelines have focused their efforts on
how it can be accurately diagnosed to prevent complications while reducing unnecessary antibiotic
prescribing.
Objective
This clinical pathway was developed to serve as guidance for family and community medicine
practitioners in making clinical decisions regarding the diagnosis and management of acute
tonsillopharyngitis.
Methods
After defining the scope of the pathway, the PAFP Clinical Pathways Group first identified the key
issues in managing patient with acute tonsillopharyngitis. These key issues were then translated to
review question. The group then reviewed the published medical literature to identify, summarize, and
operationalize the evidence in clinical publication. Databases were first searched for existing clinical
practice guidelines from reputable medical organizations. Further search for evidence was also
conducted using the terms “tonsillopharyngitis” or “tonsillitis”, “diagnosis” and “treatment”. Evidence
was then summarized and its quality assessed using the modified GRADE approach. From the
evidence-based summaries, the CPDG then developed general guideline and pathway
recommendations which are stated as time-bound tasks of patient-care processes in the management
of acute tonsillopharyngitis in family and community practice. The recommendations were then
presented to a panel of family and community practitioners in both urban and rural settings, for a
consensus agreement on the applicability of the recommendations to family and community practice.
Lastly, the final clinical pathway was written and developed to include the recommendations, the
clinical pathway tables, and an algorithm. The clinical pathway can be used as a checklist or standards
of care. The algorithm can be used to explain the process of care to the patient
Recommendations
This clinical pathway contains updates on recommendations in the 2010 clinical practice guidelines on
acute tonsillopharyngitis. Recommendations on the utilization of clinical scoring and rapid antigen
tests as basis for deciding on need for antibiotic therapy comprise the major changes from the
previously published guidelines. Penicillin remains as the first-line antibiotic therapy for streptococcal
throat infection.
SUMMARY OF RECOMMENDATIONS
History and Physical Exam
FIRST VISIT
Elicit history of throat pain and its intensity, fever and painful lymph nodes on the neck and duration of
symptoms. (AII)
Elicit history of recurrent tonsillopharyngitis, peritonsillar abscess and drug allergies (AII)
Evaluate socioeconomic status (BII)
Examine for fever, tonsillar swelling, exudates, and cervical lymphadenitis. (AII)
Examine for signs of dehydration (BIII)
Obtain the Centor or FeverPAIN score to determine probability of streptococcal infection (AII)
SECOND VISIT
Re-evaluate the presence of throat pain and its intensity, fever, tonsillopharyngeal congestion, and tonsillar
exudates (AII)
Assess adherence to treatment (AII) and explore reasons for non-adherence (AIII)
Ask for presence of any adverse drug event (AIII)
Examine for signs of suppurative complications if with no improvement in symptoms (AII)
Diagnostic Exam
Offer rapid antigen test for Streptococcal infection to patients 3 years of age and older with Centor score of
≥3, if available (CII)
Offer throat swab and culture if initial antibiotic treatment fails (AII)
Pharmacologic Intervention
FIRST VISIT
Offer symptomatic treatment with paracetamol or NSAID in lozenge or oral form. (AI)
In adult patients with more severe presentations e.g Centor score ≥3 , consider offering a single low-dose
corticosteroid (AI)
Antibiotics should only be offered if the rapid antigen test is positive or if Centor score is ≥3 or FeverPAIN
score is ≥4. Penicillin or Amoxicillin is given as first-line antibiotic treatment. Cephalosporins and
macrolides are given in case of allergies to penicillin (AI)
SECOND VISIT
If with symptom improvement within 1 week, complete the prescribed antibiotic regimen (AI)
If with no improvement or if with worsening of symptoms despite adherence or if with adverse reactions to
the previously prescribed antibiotics, offer change in antibiotics (AII)
If no improvement or worsening of symptoms because of poor adherence, continue the first antibiotic
prescribed and complete the prescribed regimen (AIII)
Non-pharmacologic Intervention
Advise increase oral fluid intake for adequate hydration and soft diet (AIII) for patients with odynophagia
and consider home remedies such as salt-water gargles (AII)
Consider offering chlorhexidine plus benzydamine combination throat spray (AI), if available or
chlorhexidine or benzydamine oral spray for symptomatic relief (AII)
Educate regarding possible etiologies of acute pharyngitis, transmission, and complications of Streptococcal
pharyngitis (AIII)
Educate regarding the dose, frequency, possible adverse effects of medications and the importance of
completing the prescribed antibiotic regimen (AII)
To reduce transmission, educate regarding cough and sneeze etiquette and hand hygiene and advise to stay
home until afebrile and/or completion of ≥ 24 hours of appropriate antibiotic therapy (AIII)
Educate the family regarding possible etiologies of acute pharyngitis, transmission, treatment and
complications of Streptococcal pharyngitis (AIII)
Explore and educate on exposure to possible irritants in the community and the workplace (AIII)
SECOND VISIT
If symptoms are still present, reinforce advice on use of supportive treatment and home remedies for
symptomatic relief (AII)
Reinforce health education regarding possible complications and treatment of Streptococcal pharyngitis
(AIII)
Reinforce education on hand hygiene and cough and sneeze etiquette to reduce transmission (AIII)
Reinforce education on the proper dosage and intake of antibiotics (AII) and provide counseling on adherence
to medications (AII)
Reinforce health education regarding transmission, treatment and possible complications of Streptococcal
pharyngitis (AIII)
Reinforce advice on avoidance of exposure to possible irritants in the community and the workplace (AIII)
Patient Outcomes
Receives information about acute tonsillopharyngitis – possible etiologies and complications and agrees with
pharmacologic and non-pharmacologic treatment plan (AIII)
Aware of the dose, frequency, indications and side effects of the medications given (AII)
Aware of the importance of compliance with antibiotic treatment and follow-up (AII)
Advise patient to follow-up after 7 days to assess for improvement or at any time if with worsening of
symptoms (AII)
Symptom improvement or resolution (AII)
Implementation
Implementation of the clinical pathway will be at the practice and the organizational levels. The
pathway may be used as a checklist to guide family medicine specialists or general practitioners in
individual clinic and community medicine practice. It may also be used as reference for exams by the
training programs and the specialty board. In the commitment to achieve the goal of improving the
effectiveness, efficiency and quality of patient care in family and community practice, the clinical
pathway may also be implemented through quality improvement activities in the form of patient record
reviews, audit and feedback. Audit standards will be the assessment and intervention recommendations
in the clinical pathway. Organizational outcomes can be activities of the PAFP devoted to the
promotion, development, dissemination and implementation of clinical pathways.
Pathway Recommendations
VISIT
PATHWAY TASKS
History and Physical Examination
FIRST
VISIT
For ALL patients presenting with
acute sore throat:
__ Elicit history of throat pain and its
intensity, fever and painful lymph
nodes on the neck and duration of
symptoms. (AII)
__Elicit history of recurrent
tonsillopharyngitis and peritonsillar
abscess and drug allergies (AII)
__Evaluate socioeconomic status (BII)
Diagnostic tests
Pharmacologic Intervention
__Offer rapid antigen test for
Streptococcal infection to
patients 3 years of age and
older with Centor score of ≥3, if
available (CII)
__Offer symptomatic treatment with paracetamol
or NSAID in lozenge or oral form. (AI)
__In adult patients with more severe
presentations e.g Centor score 3-4 , consider
offering a single low-dose corticosteroid (AI)
__Antibiotics should only be offered if the rapid
antigen test is positive or if Centor score is ≥3 or
FeverPAIN score is ≥4. Penicillin or Amoxicillin
is given as first-line antibiotic treatment.
Cephalosporins and macrolides are given in case
of allergies to penicillin (AI)
__Examine for fever, tonsillar
swelling, exudates, and cervical
lymphadenitis. (AII)
Non- pharmacologic Intervention
Patient Intervention
__ Advise increase oral fluid intake for adequate
hydration and soft diet for (AIII) patients with
odynophagia and consider home remedies such as
salt-water gargles (AII)
__Consider offering chlorhexidine plus benzydamine
combination throat spray, if available (AI) or
chlorhexidine or benzydamine oral spray (AII) for
symptomatic relief
__Educate regarding possible etiologies of acute
pharyngitis, transmission, and complications of
Streptococcal pharyngitis (AIII)
__Educate regarding the dose, frequency, possible
adverse effects of medications and the importance of
completing the prescribed antibiotic regimen (AII)
__Examine for signs of dehydration
(BIII)
__ To reduce transmission, educate regarding cough
and sneeze etiquette and hand hygiene and advise to
stay home until afebrile and/or completion of ≥ 24
hours of appropriate antibiotic therapy. (AIII)
__Obtain the Centor or FeverPAIN
score to determine probability of
streptococcal infection (AII)
Patient Outcomes
__ Receives information about acute
tonsillopharyngitis – possible
etiologies and complications and
agrees with pharmacologic and nonpharmacologic treatment plan (AIII)
__Aware of the dose, frequency,
indications and side effects of the
medications given (AII)
__ Aware of the importance of
compliance with antibiotic treatment
and follow-up (AII)
Follow-up Visit
__Advise patient to follow-up after 7
days to assess for improvement or at
any time if with worsening of
symptoms (AII)
Family Intervention
__Educate the family regarding possible etiologies of
acute pharyngitis, transmission, treatment and
complications of Streptococcal pharyngitis (AIII)
Community-level Intervention
__Explore and educate on exposure to possible
irritants in the community and the workplace (AIII)
Variation
Discuss referral to specialist and the
possibility of tonsillectomy if with
recurrent tonsillopharyngitis
For patients with FeverPAIN score 2-3, consider
offering a back-up antibiotic prescription if
symptoms deteriorate rapidly or significantly, or
do not improve within 3 to 5 days
Understands when referral for
tonsillectomy is necessary
VISIT
PATHWAY TASKS
History and Physical Examination
SECOND
VISIT
__Re-evaluate the presence of throat
pain and its intensity, fever,
tonsillopharyngeal congestion, and
tonsillar exudates (AII)
__ Assess adherence to treatment (AII)
and explore reasons for non-adherence
(AIII)
__ Ask for presence of any adverse drug
event (AIII)
__ Examine for signs of suppurative
complications if with no improvement in
symptoms (AII)
Diagnostic Tests
__Offer throat swab and culture if
initial antibiotic treatment fails (AII)
Pharmacologic Intervention
__ If with symptom improvement
within 1 week, complete the
prescribed antibiotic regimen (AI)
Non- pharmacologic Intervention
Patient Intervention
__If symptoms are still present, reinforce advice on
use of supportive treatment and home remedies for
symptomatic relief (AII)
Patient Outcomes
__Symptom improvement or resolution
(AII)
__If with no improvement or if with
worsening of symptoms despite
adherence or if with adverse reactions
to the previously prescribed
antibiotics, offer change in antibiotics
(AII)
__Reinforce health education regarding possible
complications and treatment of Streptococcal
pharyngitis (AIII)
__For non-improving cases and antibiotic
was changed or shifted, patient agrees with
new antibiotic treatment and understands
its dose, frequency, indication and possible
side effects (AII)
__If no improvement or worsening of
symptoms because of poor adherence,
continue the first antibiotic prescribed
and complete the prescribed regimen.
(AIII)
__Reinforce education on hand hygiene and cough
and sneeze etiquette to reduce transmission (AIII)
__Aware of the diagnostic test if any will
be conducted, its benefit and harm (AIII)
__Reinforce education on the proper dosage and
intake of antibiotics (AII) and provide counseling
on adherence to medications (AII)
Family Intervention
__Reinforce health education regarding
transmission, treatment and possible complications
of Streptococcal pharyngitis (AIII)
Community-level Intervention
__Reinforce advice on avoidance of exposure to
possible irritants in the community and the
workplace (AIII)
Variation
Discuss the possibility of referral to
specialist if there is failure of treatment
or signs of suppurative complications
despite adequate adherence to treatment.
Understands when referral for
tonsillectomy is necessary