QuestionSBA
QuestionChoice
NICE recommend using either the FeverPAIN criteria or Centor criteria to identify which patients are more likely to benefit from antibiotics. This patient has a FeverPAIN score of 5 (for fever, purulence, attended rapidly, inflamed tonsils, and no cough or coryza) and a Centor score of 3 (tonsillar exudate, history of ever and s=absence of cough). Both of these mean that the patient should receive antibiotics. The first line for a patient not allergic or intolerant to penicillin is phenoxymethylpenicillin. In patients who are penicillin allergic or intolerant, alternative antibiotic choices include clarithromycin or erythromycin
31938
a
Prescribe phenoxymethylpenicillin 500mg QDS for 5 days
QuestionChoice
Doxycycline is not indicated for use in tonsillitis. Doxycycline is most commonly used in respiratory tract infections particularly in those who are penicillin allergic or intolerant
31942
e
Prescribe doxycycline 200mg for 1 dose, then maintenance 100mg OD for 5 days total
QuestionChoice
Antibiotic are indicated in this patient as he has a FeverPAIN score of 5 or a Centor score of 3
31940
c
Reassure and explain that there is no indication for antibiotics at present
QuestionChoice
Amoxicillin is not indicated for use in tonsillitis. Common indications for amoxicillin include respiratory tract and urinary tract infections
31941
d
Prescribe amoxicillin 500mg TDS for 5 days
QuestionChoice
There is no indication that this patient would not, at present, be able to manage at home. Indications for referral to hospital would include stridor, clinical suspicion of acute epiglottitis, dehydration, or signs of any complications. He does not appear to be systemically unwell from his observations. Immunosuppression is another indication to urgently refer to hospital, which we have no reason to think that this patient is
31939
b
Refer urgently to hospital
QuestionComment
doesnt centor criteria need fever of >38.5?
11840
QuestionComment
>38 I believe
23308
User
subscriber
Tazocin Biopsy
QuestionComment
silly question
23625
User
subscriber
Ketone Migraine
User
subscriber
Axillary Stasis
QuestionComment
Swear the prescription is for 10 days and not 5 which is what threw me off
40599
User
subscriber
ButtMuncher
Concept
Chapter
# Summary
 
Tonsillitis is an acute inflammation of the tonsils, often with a purulent exudate in bacterial cases. The most common cause of tonsillitis are viruses, however, the most common bacterium causing tonsillitis is Streptococcus pyogenes (group A streptococcus). The CENTOR criteria can be used to determine the likelihood of a bacterial infection, and management of bacterial tonsillitis often involves antibiotic treatment. Key signs and symptoms can include tonsillar exudate, tender anterior cervical lymphadenopathy, fever over 38 degrees Celsius, and absence of a cough. 
  
# Definition
 

Tonsillitis is a form of pharyngitis characterised by acute inflammation of the tonsils, often with a purulent exudate present in bacterial tonsillitis.
 

# Epidemiology
 

In the UK, tonsillitis is a common condition that predominantly affects children and adolescents, with an estimated 7.4% of GP consultations for children under 15 years involving a sore throat or tonsillitis as the primary reason for the visit.
 

# Aetiology
 

The most common causative organism of tonsillitis is Streptococcus pyogenes (group A streptococcus). Epstein-Barr virus (EBV) is another common cause.
 
Risk factors for tonsillitis include:
 
 - Age 5-15 years
 - Immunodeficiency 
 - Family history of tonsillitis 
 - Close contact with an infected individual 
 

# Signs and Symptoms 
 
 - Sore throat 
       - The child may also complain of referred pain in the ears or a headache 
 - Changes to the sound of the child's voice or cry 
 - Purulent and inflamed tonsils
 - Lymphadenopathy 
 

# Differential Diagnosis
 

Differential diagnoses for tonsillitis include the following:
 

 - **Bacterial Tonsillitis**: Main signs and symptoms include cervical lymphadenopathy, tonsillar exudate, and fever.
 - **Viral Tonsillitis**: Symptoms are often milder, and accompanied by coryzal symptoms (i.e. cough, rhinorrhoea). 
 - **Infectious Mononucleosis**: Also known as glandular fever, this is more common in teenagers. This presents with enlarged tonsils, fatigue and occasionally with splenomegaly. 
 - **Hand, foot and mouth disease**: This is caused by the Coxsackie virus, and will feature blisters on the tonsils and roof of the child's mouth. Blisters may also be found on the feet and hands.
 

# Investigations
 

The CENTOR criteria can be used to indicate the likelihood of a sore throat being due to a bacterial infection. The criteria are as follows:
 

 1. Tonsillar exudate
 2. Tender anterior cervical lymphadenopathy
 3. Fever over 38 degrees Celsius
 4. Absence of a cough
 

 [lightgallery]
 

Each of the CENTOR criteria scores 1 point, with a maximum score of 4. A score of 0, 1 or 2 is thought to be associated with a 3 to 17% likelihood of isolating Streptococcus. A score of 3 or 4 is thought to be associated with a 32 to 56% likelihood of isolating Streptococcus.

Alternatively, the FeverPAIN score can be used. The criteria for this include:

- **Fever**
- **P**us on tonsils
- **A**ttended within 3 days of symptom onset
- **I**nflamed tonsils
- **N**o cough or coryza 

Diagnosis is usually clinical, however, in some cases, further investigations may include:

- Throat swab for microscopy and culture
- Monospot (heterophile antibody) test for glandular fever 
 

# Management
 

Bacterial tonsillitis with a CENTOR criteria score of 3/4, FeverPAIN score of 4 or 5, or evidence of systemic upset/immunosuppression warrants prescribing antibiotics:
 

-  1st line: Penicillin V PO QDS for 5-10 days
    -  Dose is dependent on age, see BNFc for dosing 
-  Alternative in penicillin allergy: Clarithromycin/Erythromycin PO BD for 5 days
    -  Dose is dependent on age, see BNFc for dosing 

For patients with a CENTOR score of 0-2 or FeverPAIN score of 0 or 1:

- Advise that antibiotics are not needed as they do not tend to alter how long symptoms last and may cause side effects such as diarrhoea and nausea.
- Conservative management including paracetamol for analgesia and ensuring adequate fluid intake. 

If the child is systemically very unwell or has severe complications, consider referring the child to the hospital. 

# Complications

- Quinsy (peritonsillar abscess)
- Acute otitis media 
- If tonsillitis is due to Group A beta haemolytic step:
    - Rheumatic fever
    - Syndenham's chorea 
    - Glomerulonephritis 
    - Scarlet fever 

# Prognosis 

Tonsillitis is usually self-resolving within 3-4 days. Some children will have recurrent tonsillitis, and this recurrence may be reduced by smoking cessation for the parents or through tonsillectomy. 

Tonsillectomy may be indicated for severe recurrent tonsillitis (more than 7 episodes/year for one year, more than 5 episodes/year for two years and more than 3 episodes per year for 3 years). This may be done via diathermy or coblation. 


# NICE Guidelines

[NICE Guidelines Sore Throat (acute)](https://www.nice.org.uk/guidance/ng84) 

[NICE Flowsheet on Antimicrobial Prescribing](https://www.nice.org.uk/guidance/ng84/resources/sore-throat-acute-in-adults-antimicrobial-prescribing-visual-summary-pdf-11315864557) 
 

# References
 
[NHS Information on Tonsillitis](https://www.nhs.uk/conditions/tonsillitis/)

[Patient Info Tonsillitis](https://patient.info/doctor/tonsillitis-pro) 

[Great Ormond Street Hospital Tonsillectomy](https://www.gosh.nhs.uk/conditions-and-treatments/procedures-and-treatments/your-child-having-his-or-her-tonsils-andor-adenoids-removed/)
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Picture
An example of a right sided quinsy.
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Peritonsilar abscess.jpeg
images/n2yy75x31665036171698.jpg
images/n2yy75x31665036171698_256.jpg
images/n2yy75x31665036171698_512.jpg
IYkODgR6iAiWeHh4d3l1ZXiIo49L9To=
2332
Tonsillitis
Topic
24
Ear, Nose & Throat
6388
In cases of acute pharyngitis with purulent tonsillitis, phenoxymethylpenicillin is the first-line antibiotic treatment if the patient is not penicillin allergic.
A 25 year old man presents to his general practice with a sore throat which started 2 days ago. He also reports feeling feverish and unwell and denies a cough or coryza. He is still able to eat and drink. He has no allergies and does not take any regular medications.

His observations are as follows:

- Heart rate: 70 beats per minute
- Blood pressure: 115/80mmHg
- Respiratory rate: 14 breaths per minute
- Saturations: 99% on room air
- Temperature: 38.1 degrees Celsius

On examination, his tonsils are inflamed and purulent. He does not have any tender cervical lymphadenopathy.

What is the next best step in the management of this patient?
a