Tonsillitis

Key NICE recommendations on management

This summary covers antimicrobial prescribing recommendations for acute sore throat.

Assess and manage children under 5 who present with fever as outlined in the NICE guideline Fever in under 5s: assessment and initial management (NG143).​

When managing acute sore throat, including when making decisions about antibiotic prescribing, you should take into account that:

• It is self-limiting and often triggered by a viral infection of the upper respiratory tract

• There is evidence that antibiotics make little difference to how long symptoms last, and most people will get better within 1 week without antibiotics, regardless of whether the cause is viral or bacterial.

Reassess at any time if symptoms worsen rapidly or significantly. Take account of:

• Alternative diagnoses (e.g., scarlet fever or glandular fever), and evaluate for any symptoms or signs suggesting a more serious illness or condition

• Previous antibiotic use, which may lead to resistant organisms.

Treating symptoms

Consider paracetamol (first-line) or ibuprofen for pain and fever, and advise about adequate intake of fluids.

Advise adults who may wish to try medicated lozenges (containing either a local anaesthetic, a non-steroidal anti-inflammatory drug, or an antiseptic) for pain, that these may only help to reduce pain by a small amount.

Antibiotic treatment

Offer an immediate antibiotic prescription to people who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications.

• Refer people to hospital if they have acute sore throat associated with a severe systemic infection or with severe suppurative complications (such as quinsy [peri-tonsillar abscess] or cellulitis, parapharyngeal abscess or retropharyngeal abscess or Lemierre syndrome).

For all other people, use FeverPAIN or Centor criteria to identify those who are more likely to benefit from an antibiotic.

Offer either an immediate or a back-up antibiotic prescription if the person has a FeverPAIN score of ≥4, or a Centor score of ≥3. Consider offering a back-up antibiotic prescription if the person has a FeverPAIN score of 2 or 3.

• Consider the potential adverse effects of antibiotics (particularly diarrhoea and nausea). Complications of acute sore throat are generally rare in adults and children and are unlikely to arise if antibiotics are withheld.

Do not offer an antibiotic prescription if the person has a FeverPAIN score of ≤1, or Centor score of ≤2.

Choice of antibiotic

Prescribe a 5 to 10 day course of oral phenoxymethylpenicillin as the first-choice oral antibiotic for adults and children with no penicillin allergy or intolerance.

• Prescribe the shortest course likely to be effective. This is to reduce the risk of antimicrobial resistance and minimise the risk of adverse effects, and may also help with medicines adherence.

• A 5-day course may be enough for symptomatic cure. In situations where there is recurrent infection, a 10-day course may increase the likelihood of microbiological cure.

If the person has a penicillin allergy or intolerance (and is not pregnant), prescribe a 5-day course of clarithromycin as an alternative first-choice antibiotic.

If the person has a penicillin allergy and is pregnant (and has a compelling clinical need for an antibiotic with no suitable alternatives to macrolides), prescribe a 5-day course of erythromycin as an alternative first-choice antibiotic after an informed discussion of the potential benefits and harms of treatment.

• Evidence is insufficient to confirm with certainty whether there is a small increased risk of birth defects or miscarriage when macrolides are taken in early pregnancy.

• Erythromycin is preferred if a macrolide is needed in pregnancy (e.g., if there is true penicillin allergy and the benefits of antibiotic treatment outweigh the harms) because there is more documented experience of its use than for other macrolides.

Patient advice

Advise people about the usual course of acute sore throat (symptoms can last around 1 week) and to seek medical help if symptoms worsen rapidly or significantly, or if they become systemically very unwell.

Further tailored advice should be given depending on whether an antibiotic prescription is offered:

• Where no antibiotic prescription is given, advise that an antibiotic is not needed and to seek medical help if symptoms do not start to improve after 1 week

• Where a back-up antibiotic prescription is given, advise that an antibiotic is not needed immediately, and to use the back-up prescription if symptoms do not start to improve within 3 to 5 days or if they worsen rapidly or significantly at any time.

© NICE (2018) All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England https://www.nice.org.uk/terms-and-conditions#notice-of-rights . All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.