• Summary
  Click here to print a Quick Reference Guide
• Background
• Clinical Diagnosis
• Investigation
• Treatment
• Non-Antimicrobial Treatment
• Empirical Antimicrobial Treatment
• Directed Antimicrobial Treatment (when microbiology results are known)
• Duration of Treatment
• Switch to oral agent(s)
• Treatment Failure
• Referral Criteria

Summary/Quick reference guide

History - assess:

• Rapidity of onset of sore throat.
• Difficulty breathing/speaking.
• Ability to eat/drink/swallow.
• Associated neck pain/swellings.
• Symptoms of systemic infection e.g. fever, chills, rigors, lethargy.
• Travel and vaccination history.

Examination -- assess

• Airway - patients with stridor need urgent senior review.
• Ability to swallow - patients unable to swallow secretions (drooling) need urgent ENT / Senior assessment (do not examine oral cavity).
• Examine oropharynx for trismus, erythema and tonsillar size
• Examine head and neck lymph nodes.
• Check PAWS score and use traffic light system to assess for severe infection (table 1).

Table 1. Alert features in children with acute sore throat.

Suspect epiglottitis in children with sudden onset of severe sore throat, drooling and systemic symptoms/signs of infection.

Diagnose acute tonsillar pharyngitis in children with symmetrically inflamed tonsils and pharynx.

Severe infection = PAWS >10 OR any “red” or “yellow” features OR unable to swallow.
Non-severe infection = PAWS ≤10 AND NO red or yellow features AND able to swallow.

Consider infectious mononucleosis in children with symmetrically inflamed tonsils / soft palate inflammation and posterior cervical lymphadenopathy

Investigations required:
Non-severe infection: No routine investigations, unless infectious mononucleosis is suspected (see below).

severe infection:

• Blood cultures, full blood count, urea and electrolytes and liver function tests
• Suspected infectious mononucleosis: blood sample for Monospot or EBV VCA (viral capsular antigen) IgM and IgG antibody and EBNA IgG

Non-Antimicrobial Management

Patients with stridor or suspected epiglottitis:

• Supplemental humidified high flow oxygen should be provided.
• Nebulised adrenaline (1mg adrenaline in 5mls sodium chloride 0.9%) in children with rapidly deteriorating symptoms prior to securing an airway.
• Give helium/oxygen mixture (Heliox) if hypoxic in spite of supplemental oxygen.
• Establish an appropriate airway.
• A senior anaesthetist and senior ENT surgeon (Registrar or above) should be present.
• Patients should be intubated preferably in theatre with the ability to perform an emergency tracheostomy if intubation fails.

All patients:

• Analgesia e.g. paracetamol or ibuprofen.
• Aspiration of peritonsillar / parapharyngeal abscess (Quinsy) by ENT if present.

Antimicrobial treatment

Most acute sore throats do not require antibiotics.
Treat patients with severe acute tonsillar pharyngitis or epiglottitis.
Consider antimicrobials in non severe acute tonsillar pharyngitis if symptoms present for 1 week and getting worse.

Please refer to the following Group A streptococcus interim clinical guidance issued by the UK Health Security Agency report released on 2nd December 2022, for the management of patients with sore throat with/without symptoms of scarlett fever: NHS England » Group A streptococcus interim clinical guidance.

Please continue to use the trust guidance below for severe acute tonsillar pharyngitis or epiglottitis.

Table 2. Empirical treatment regimens for children with tonsillitis or epiglottitis. *doses may need amending in renal impairment/failure.
Treatment course 10 days for penicillin, 7 days for Clarithromycin . Convert to oral medication after 24 hours if able to swallow and other oral switch criteria satisfied.

Referral criteria
In addition to above, patients with a suspected peritonsillar or retropharyngeal abscess should be referred urgently to ENT

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The term acute sore throat describes the rapid onset of pain in the throat due to inflammation. This is usually caused by infection of the oropharynx and/or tonsils. Epiglottitis is a rare but serious cause of acute sore throat.

Acute tonsillar pharyngitis
Acute tonsillar pharyngitis is commonly caused by viruses, however in a third of people, no cause can be found¹.
Common infectious causes include¹:

• Rhinovirus, coronovirus, parainfluenza virus (25% of sore throats).
• Influenza types A and B (4% of sore throats).
• Adenovirus (4% of sore throats).
• Herpes simplex virus type 1 (and more rarely type 2):(2% of sore throats).
• Epstein-Barr virus (glandular fever, < 1% of sore throats).
• Streptococcal infection. Group A beta-haemolytic Streptococcus (GABHS) is the most common bacterial cause of sore throat. (15–30% of sore throats in children, and 10% in adults). Group C and G beta-haemolytic streptococci can also cause acute tonsillar pharyngitis.
• Chlamydophylla pneumoniae and Mycoplasma pneumoniae are probably an under diagnosed cause of acute sore throat.

Rare cause of tonsillar pharyngitis:

• Neisseria gonorrhoeae (Gonococcal pharyngitis)
• HIV-1
• Corynebacterium diphtheriae (Diptheria)
• Acanobacterium haemolyticum

How common is it?
A GP with 2000 patients will see around 120 people with an acute throat infection every year². In 1996 acute tonsillitis was the 8th commonest acute presentation to a GP practice. However, most people with sore throat do not visit their GP: one UK study found that only 1 in 18 episodes of sore throat led to a GP consultation³. Admission to hospital with severe infection is uncommon and peritonsillar abscesses are very rare in children.

Natural History?
Sore throat due to a viral or bacterial cause is usually a self-limiting condition. Symptoms resolve within three days in 40% of people, and within one week in 85% of people, irrespective of whether or not the sore throat is due to a streptococcal infection^{4, 5}. The symptoms of infectious mononucleosis (Glandular fever) usually resolve within 1–2 weeks although mild cases may resolve within days. However lethargy often continues for some time afterwards and in rare cases may continue for months or years⁶.

Epiglottitis
Epiglottitis, also termed supraglottitis, is an inflammation of structures above the glottis. The condition is usually caused by bacterial infection. Affected structures include the epiglottis, aryepiglottic folds, arytenoid soft tissue, and, occasionally, the uvula⁷. The epiglottis is the most common site of swelling. Acute epiglottitis and associated upper airway obstruction has significant morbidity and mortality and may cause respiratory arrest and death within 24 hours.

Causes of epiglottitis⁷:
Haemophilus influenzae type b (Hib) was the commonest cause and the aetiological agent in more than 90% of paediatric epiglottitis cases but the Hb vaccine has significantly reduced the rate of epiglottis (1)⁸

• Other known bacterial causes include the following:
  • Streptococcus pneumoniae
  • Group A and group C (ie, beta-hemolytic) streptococci
  • Staphylococcus aureus
  • Moraxella catarrhalis
  • Haemophilus parainfluenzae
  • Neisseria meningitidis
  • Pseudomonas species
  • Candida albicans
  • Klebsiella pneumoniae
  • Pasteurella multocida
• Although viruses normally do not cause epiglottitis, a prior viral infection may allow bacterial superinfection to occur. Viral agents may include herpes simplex, parainfluenzae, varicella-zoster, and Epstein-Barr.
• Noninfectious aetiologies include thermal injuries, trauma, angioneurotic oedema, and acute leukaemia.

Persisting sore throat
Patients presenting with a persistently sore throat for more than three weeks should have their diagnosis reviewed. Consider non-infectious causes of sore throat (for example, gastro-oesophageal reflux disease or chronic irritation from hay fever).

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Symptoms of tonsillitis and or pharyngitis are usually mild but severe pharyngeal pain, painful swallowing, headache, and a high temperature may be present¹. Children may complain of a tender neck due to enlarging lymphadenopathy or otalgia due to referred pain.
In practice it is not usually possible to distinguish between the different microbial causes of acute sore throat on clinical grounds. In particular it is not possible to diagnose acute streptococcal sore throat on clinical features alone.

Unilateral symptoms typically with referred otalgia, trismus and a ‘hot potato’ characteristic when speaking may indicate a developing a peritonsillar abscess (Quinsy). A peritonsillar abscess is rare in children as compared to adults
Infectious mononucleosis presents in most children as a clinical triad of sore throat, fever, and lymphadenopathy. Sore throat is the most frequent complaint and jaundice may develop. It is usually severe for 3–5 days and then gradually resolves over 7–10 days. The degree of malaise is often out of proportion to the clinical picture^{1, 6, 9}.

Epiglottitis is characterized by abrupt onset of severe sore throat with painful swallowing / drooling that may rapidly progress to respiratory obstruction and death in a matter of hours. Fever is usually the first symptom and temperatures often reach 40°C. This is rapidly followed by stridor and laboured breathing. Dysphagia, refusal to eat, muffled (ie, guttural) or hoarse voice, and sore throat are common ¹⁰. A study of 35 people (34 adults and 1 infant) presenting with epiglottitis in Denmark found that 94% had painful swallowing, 60% had drooling, 57% had a history of fever, and 29% had a muffled voice. Only 4% had stridor ¹¹.

Examination
The tonsils are inflamed and may be enlarged. A patchy grey-yellow exudate is often present on the tonsils and the uvula may be oedematous. The cervical lymph nodes, especially jugular digastric are enlarged and tender ¹. If the tonsils are significantly enlarged stertor (a harsh inspiratory noise generated due to oropharyngeal congestion -not stridor) may be present. In severe cases patients may be dehydrated due to the difficulty in swallowing.

Figure 1 Acute Tonsillitis (viral or bacterial)

Figure 2 Acute tonsillar-pharyngitis

Children rarely present with a peritonsillar abscess (Quinsy) but would have an apparent unilateral tonsillar enlargement due to a collection of pus pushing the tonsil towards the midline. The uvula may be deviated and the abscess may point through the soft palate. The collection of pus around the pterygoid muscle results in trismus with poor mouth opening.

Rarely other suppurative complications may occur. Spreading sepsis may result in a retropharyngeal or parapharyngeal abscess or thrombosis of the internal jugular vein (Lemiere’s Syndrome).

Figure 3 Right peritonsillar abscess

Children with infectious mononucleosis typically have a fever of 38–39°C. Cervical lymphadenopathy is symmetrical and includes the posterior triangle lymph nodes. The tonsils are usually symmetrically enlarged, occasionally meeting in the midline and the pharynx may be erythematous with exudate. Palatal petechiae may be present but are not diagnostic of infectious mononucleosis. Splenomegaly occurs in over 50% of patients and is maximal at the beginning of the second week^{9, 12}. A few children with infectious mononucleosis may develop jaundice, hepatomegaly, or a rash which may be macular, petechial, scarletiniform, urticarial, or like erythema multiforme.

Figure 4 Infectious mononucleosis

In children with epiglottitis examination of the oral cavity is not recommended however if seen it is usually normal¹

Figure 5 Epiglottitis

Admission criteria for acute sore throat [Evidence level D]:

1. Severe infection.
   • Signs of being markedly systemically unwell (see table 1).
   • Stridor, stertor, respiratory distress (See table 1)
   • Unable/reluctant to swallow (drooling) or dehydrated.
2. Suspected suppurative complications (e.g. peri-tonsillar abscess, para-pharyngeal abscess, retropharyngeal abscess, or Lemiere syndrome -thrombosis of the jugular vein) as there is a risk of airway compromise or rupture of the abscess.
   • Immunosuppression. (severe, primarily neutropaenic patients or those on chemotherapy.)

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Suspected tonsillar-pharyngitis:

• Recommendation: In children presenting with non severe acute tonsillar pharyngitis no investigations are required. [Evidence level B]

• Recommendation: Throat swabs should not be carried out routinely in the investigation of acute sore throat. Throat swabs cannot differentiate between infection and carriage/colonisation, they have poor sensitivity, results take up to 48 hours to be reported and the analysis is relatively expensive ^{3, 13}. [Evidence level B]

• Recommendation: Rapid antigen tests for detection of group A streptococcal antigen on a throat swab are not recommended. Although these tests produce results within a few minutes they have poor sensitivity and make little impact on prescribing decisions ^{3, 14}. [Evidence level B]

• Recommendation: Children with severe tonsillar-pharyngitis who are being admitted for intravenous antimicrobials should have the following tests: full blood count, white cell count, urea and electrolytes and blood cultures. [Evidence level D]

N.B Group A beta-haemolytic streptococci (GABHS) can be isolated from up to 30% of people presenting with sore throat ¹. However, figures for asymptomatic carriage range from 6% to 40%¹³. Carriers have low infectivity and are not at risk of developing complications.

Suspected peritonsillar abscess, retropharyngeal abscess

Recommendation: Children with suspected peritonsillar abscess, retropharyngeal abscess should be referred to ENT and considered for aspiration or drainage. Aspirates should be sent for microscopy and culture. [Evidence level C]

Suspected infectious mononucleosis (glandular fever):

Recommendation: The following tests should be done:

• Full blood count, differential white cell count and blood film, Urea and electrolytes, Liver function tests.
• Heterophile antibodies (Monospot): N.B High false negative in children especially under the age of 2. False negative results are less likely after the second week of the illness. False-negative rates may be 25% in week one of infection, falling to approximately 5% in week three.
• EBV VCA (viral capsular antigen) IgM and IgG antibody and EBNA IgG.

EBV IgM -In children under 12 years of age and in people who are immunocompromised at any age, viral serology for the Epstein-Barr virus is preferred as the monospot test has a high false negative rate. A positive EBV VCA IgM result with negative EB VCA IgG and negative EBNA IgG supports the diagnosis of acute EBV infection.

Suspected epiglottitis:

Recommendation: The following tests should be done after securing the airway:

• Blood culture x2 (Hib in 12-90% of cases)
• Swab of epiglottis obtained under direct vision (usually at endoscopy) (positive in 50% of cases)
• Full blood count, white cell count, urea and electrolytes and blood cultures.

[Evidence level D]

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Suspected epiglottitis and patients with stridor

Recommendation: Supplemental oxygen should be provided. [Evidence level C]

• Nebulised adrenaline (1mg adrenaline in 5mls sodium chloride 0.9%) can be used in children with rapidly deteriorating symptoms prior to securing an airway.
• Helium/oxygen mixture (Heliox) can be used in stridulous children.

Recommendation: Establish an appropriate airway. [Evidence level B]

• A senior anaesthetist and senior ENT surgeon should be present.
• Children should be intubated preferably in theatre with the ability to perform an emergency tracheostomy if intubation fails.

Mortality rates for those who receive endotracheal intubation are less than 1%. Children who do not receive intubation have mortality rates as high as 10% ^{7, 10}.

All Children with sore throat

Analgesia

Recommendation: Oral analgesics (e.g. paracetamol or ibuprofen) are recommended for the symptomatic relief of sore throat ³. A systematic review found systemic analgesics (paracetamol, nonsteroidal anti-inflammatory drugs) to be helpful in relieving symptoms of sore throat¹⁵. [Evidence level A]

No RCTs were identified on the specific use of paracetamol, ibuprofen, or diclofenac alone or in comparison with each other in the treatment of acute sore throat in children. However the recognised complications of aspirin therapy, including Reye’s syndrome in children, make this agent contraindicated in patients less than 16 years.

In children with sore throat, an adequate dose of paracetamol should be used as first line treatment for pain relief as recent case reports have highlighted concern about renal toxicity in dehydrated children given ibuprofen¹⁶.

A systematic review and meta-analysis of ibuprofen and paracetamol use in febrile children and occurrence of asthma-related symptoms showed that there is a low risk of asthma-related morbidity associated with ibuprofen use in children¹⁷.

Local analgesia

Recommendation: Routine use of local analgesics is not recommended. Although licensed for symptomatic relief of sore throat, the evidence for flurbiprofen lozenges and benzydamine gargle is poor. [Evidence level C]

Surgery

Recommendation: Children with a suspected peritonsillar abscess or retropharyngeal abscess should be referred to ENT and considered for aspiration or drainage. [Evidence level C]

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See table 2 for summary.

1. Tonsillar-pharyngitis
   Prescribe antimicrobials for:
   • Children with severe infection
   • Children with non severe infection but persistent / worsening symptoms for at least one week
   • Children with immunosuppression. (severe, primarily neutropaenic patients or those on chemotherapy.)

Empirical oral therapy
Recommendation: If the child has non severe infection and is able to swallow prescribe phenoxymethylpenicillin (or Clarithromycin if the person is allergic to penicillin). [Evidence level A].

Phenoxymethylpenicillin remains the treatment of choice compared with other antibiotic options, based on the combination of its proven efficacy, narrow spectrum, safety, and low cost ^{2, 3, 19}.

Delayed prescribing strategy
Recommendations for the delayed antibiotic prescribing strategy are based on National Institute for Health and Clinical Evidence (NICE) guidelines ²³. Patients are advised to take antibiotics within 48 hours if their symptoms show any sign of worsening. However no guidelines are offered on who should be offered a delayed prescribing strategy. A Cochrane review concluded that a delayed prescribing strategy reduced antibiotic use but was no different to a 'no antibiotics' prescribing strategy regarding symptom control, patient satisfaction, or complication rates ²⁴.
This approach could be considered for patient groups in box 1.

Empirical intravenous therapy (patients admitted to hospital):
Benzylpenicillin iv (or clarithromycin iv if true penicillin allergy) until they are able to manage oral medication.
[Evidence level D]

Evidence to support the choice of antibiotic is limited and culture results from aspiration of any abscess are crucial to optimising antimicrobial treatment (see investigations/non antimicrobial management). However most studies suggest that penicillin to be an effective choice ^25-27.

1. Peritonsillar Abscess
   Arrange admission and intravenous antibiotics.
   Recommended regimen Benzylpenicillin iv
   Recommended regimen for patients with immediate-type (IgE mediated) allergy to penicillin: clarithromycin IV
   [Evidence level C]
2. Antimicrobial Management of Epiglottits
   A third-generation cephalosporin antibiotic with broad-spectrum activity against a range of bacteria, including H influenzae, Enterobacteriaceae, and Streptococci is recommended ^{7, 10}.
   Recommended regimen: cefotaxime – see Table 2
   [Evidence level C]

Recommended regimen for patients with immediate-type (IgE mediated) allergy to penicillins or cephalosporins – please contact microbiology.

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Recommendation: Antibiotics should not be routinely prescribed for acute non-severe sore throat. Antibiotics should not be prescribed to:

• Secure symptomatic relief.
• Prevent suppurative complications.
• Treat recurrent non-streptococcal sore throat.
• Prevent the development of rheumatic fever and acute glomerulonephritis.

[Evidence level A]

A Cochrane review found antibiotics confer relative benefits in the treatment of sore throat. However, the absolute benefits are modest, with antibiotics shortening the duration of symptoms by about 16 hours overall⁵. [Evidence level A]

Antibiotics are not justified to reduce the risk of serious complications resulting from an acute sore throat. This is supported by a large UK cohort study which found the number needed to treat (NNT) with antibiotics to prevent one serious complication (quinsy) was 4300 in people with sore throat ¹⁸. [Evidence level B]

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For both severe tonsillar-pharyngitis / quinsy and epiglottitis a 10–day treatment course is recommended ^{2, 3}.
[Evidence level A for tonsillar-pharyngitis and C for epiglottitis]

This is to ensure the maximal rate of eradication of the infection¹⁹. In people with group A streptococcal pharyngitis, one randomized trial found that those treated with phenoxymethylpenicillin for 7 days had a significantly greater treatment failure rate (30/96, 31%) compared with those receiving 10 days of Phenoxymethylpenicillin (17/95, 18%). Compliance rates were 66–81% of patients²⁸.

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Recommendation: For epiglottitis give intravenous antibiotics for a minimum of 48 hours. [Evidence level D]
Change to oral antimicrobials when the patient can tolerate oral fluids and antibiotics.
Oral Co-amoxiclav  is an appropriate choice in the absence of positive cultures. [Evidence level D]

age 1 month- 1 year 0.25ml/kg of 125/31 suspension every 8 hours
age 1-6 years 5ml of 125/31 suspension every 8 hours
age 6-12 years 5ml of 250/62 suspension every 8 hours
age 12-18 years one 250/125 strength tablet every 8 hours

Recommendation: Patients with severe tonsillar-pharyngitis give intravenous antibiotics for a minimum of 24 hours and change to oral when patient can manage fluids. [Evidence level C]

Recommendation: Patients with peritonsillar abscess consider oral switch after 24 hours provided the abscess has been drained.

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Empirical oral therapy for relapsing acute sore throat

When an infective sore throat recurs in children who have received antibiotic treatment, the reasons may include³:

1. inappropriate antibiotic therapy,
2. inadequate dose or duration of previous therapy
3. patient non-compliance/non-concordance
4. re-infection
5. local breakdown of penicillin by beta-lactamase producing commensals

In a child with relapsing infection (e.g. within a six week period) it may be appropriate to take a throat swab sample for culture. Cefuroxime²¹ and clindamycin²² have been shown to be superior to penicillin V in the management of children with this problem and may reduce the frequency of episodes.

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Referal critieria -acute

Refer children with suspected quinsy, retropharyngeal or parapharyngeal abscess, epiglottitis or severe sepsis to ENT as a matter of urgency. [Evidence level C]

Referrral criteria for recurrent acute tonsillitis to ENT

The following are recommended as indications for consideration of tonsillectomy for recurrent acute sore throat in both children and adults:

• sore throats are due to acute tonsillitis
• the episodes of sore throat are disabling and prevent normal functioning
• seven or more well documented, clinically significant, adequately treated sore throats in the preceding year or
• five or more such episodes in each of the preceding two years or
• three or more such episodes in each of the preceding three years.
• recurrent and severe episodes in adults.

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