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Referral and warning signs
When to refer
Refer if: Suspected peritonsillar/retropharyngeal abscess. Airway compromise. Dehydration/inability to swallow. No improvement after 48-72h of antibiotics. Recurrent severe tonsillitis (for consideration of tonsillectomy).
Red flags
- Difficulty breathing / Stridor.
- Drooling / Inability to swallow.
- Trismus (difficulty opening mouth).
- Muffled ('hot potato') voice.
- Unilateral swelling in throat.
- Neck stiffness / swelling.
- Signs of sepsis.
Signs and symptoms
- Sudden onset sore throat.
- Pain on swallowing (odynophagia).
- Fever (>38°C).
- Headache, malaise, chills.
- Enlarged, red tonsils, often with white/yellow exudates.
- Tender, enlarged anterior cervical lymph nodes.
- Palatal petechiae.
- Absence of cough, rhinorrhoea, conjunctivitis (more suggestive of bacterial vs viral).
- Scarlet fever rash (associated with some GAS strains).
Risk factors
- Age 5-15 years (peak incidence).
- Close contact settings (schools, households).
- Season (winter/early spring).
Diagnosis
Clinical assessment
Clinical suspicion based on characteristic signs/symptoms (fever, tonsillar exudates, tender nodes, absence of cough - Centor/FeverPAIN criteria useful predictors).
Differential diagnosis
- Viral pharyngitis/tonsillitis (EBV/Mononucleosis, Adenovirus, etc.).
- Peritonsillar abscess (unilateral swelling, trismus).
- Diphtheria (grey membrane).
- Oral thrush extending to pharynx.
- Agranulocytosis (severe sore throat, ulcers).
Investigations
- Rapid Strep Antigen Detection Test (RADT): High specificity, variable sensitivity. Positive result confirms GAS.
- Throat Culture: Gold standard, but takes time. Use if RADT negative but high clinical suspicion.
- Monospot test / EBV serology (if Infectious Mononucleosis suspected).
Diagnostic criteria
Positive RADT or Throat Culture for Group A Strep. OR High clinical suspicion based on scoring criteria (managing empirically).
Management
Non-pharmacological management
- Rest.
- Adequate fluid intake.
- Salt water gargles (adults).
- Avoid irritants.
Pharmacological treatment
- Analgesia/Antipyretics: Paracetamol or Ibuprofen.
- Antibiotics (To treat GAS infection & prevent Rheumatic Fever): (LOC: HC2)
- - First line: Phenoxymethylpenicillin (Penicillin V) 500mg PO QID (Adult); 10-20 mg/kg/dose QID (Child) for 10 DAYS.
- - Alternative (Parenteral): Benzathine Penicillin G 1.2 MU IM single dose (Adult); 0.6 MU (<27kg Child) IM single dose.
- - Alternative (Penicillin Allergy): Erythromycin 500mg PO QID (Adult); 12.5 mg/kg/dose QID (Child) for 10 DAYS.
- - (Amoxicillin is also effective but Pen V often preferred due to narrower spectrum).
- Viral Pharyngo-Tonsillitis: Symptomatic treatment only (analgesia, fluids).
Monitoring
Symptoms should improve within 2-3 days of starting antibiotics. Ensure full 10-day course completed to prevent ARF. Follow up if no improvement or complications develop.
Complications
- Suppurative: Peritonsillar abscess (Quinsy), Retropharyngeal abscess, Cervical lymphadenitis, Otitis media, Sinusitis.
- Non-Suppurative (Immune): Acute Rheumatic Fever (ARF), Post-Streptococcal Glomerulonephritis (PSGN).
Prevention
- Good hygiene.
- Avoiding close contact with infected individuals.
- Prompt diagnosis and adequate (10-day) antibiotic treatment of GAS infections.
Patient education
- Diagnosis (Strep throat vs viral).
- Importance of antibiotics ONLY for Strep throat.
- CRITICAL importance of completing the FULL 10-DAY antibiotic course, even if feeling better, to prevent Rheumatic Fever.
- How to take medication.
- Symptomatic relief measures.
- Contagiousness (stay home from school/work for 24h after starting antibiotics).
- When to return if not improving or complications arise.
Uganda-specific notes
GAS pharyngitis occurs, and Acute Rheumatic Fever remains a concern. Clinical scoring criteria often used due to limited access to RADT/culture. Benzathine Penicillin IM is a good option for ensuring completion of therapy.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.3.4