Acute sore throat ( including tonsillar-pharyngitis and epiglottitis ) - Management of children presenting with
|Last review: 09/01/2018|
|Next review: 17/11/2020|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2018|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the management of children presenting with acute sore throat (including tonsillar-pharyngitis and epiglottitis)
Acute sore throat ( including tonsillar-pharyngitis and epiglottitis )
Summary/Quick reference guide
History - assess:
Examination -- assess
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.
Consider infectious mononucleosis in children with symmetrically inflamed tonsils / soft palate inflammation and posterior cervical lymphadenopathy
Patients with stridor or suspected epiglottitis:
Most acute sore throats do not require antibiotics.
Table 2. Empirical treatment regimens for children with tonsillitis or epiglottitis. *doses may need amending in renal impairment/failure.
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
Rare cause of tonsillar pharyngitis:
How common is it?
Causes of epiglottitis7:
Persisting sore throat
Suspected epiglottitis and patients with stridor
Recommendation: Supplemental oxygen should be provided. [Evidence level C]
Recommendation: Establish an appropriate airway. [Evidence level B]
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
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.
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]
Recommendation: Children with a suspected peritonsillar abscess or retropharyngeal abscess should be referred to ENT and considered for aspiration or drainage. [Evidence level C]
|Empirical Antimicrobial Treatment|
See table 2 for summary.
Empirical oral therapy
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
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.
Recommended regimen for patients with immediate-type (IgE mediated) allergy to penicillins or cephalosporins – please contact microbiology.
|Directed Antimicrobial Treatment (when microbiology results are known)|
Recommendation: Antibiotics should not be routinely prescribed for acute non-severe sore throat. Antibiotics should not be prescribed to:
[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]
|Duration of Treatment|
For both severe tonsillar-pharyngitis / quinsy and epiglottitis a 10–day treatment course is recommended 2, 3.
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.
|Switch to oral agent(s)|
Recommendation: For epiglottitis give intravenous antibiotics for a minimum of 48 hours. [Evidence level D]
age 1 month- 1 year 0.25ml/kg of 125/31 suspension 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.
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:
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.
|Clinical condition:||Acute tonsillar-pharyngitis and epiglottitis|
|Target patient group:||Children with an acute sore throat|
|Target professional group(s):||Secondary Care Doctors
Primary Care Doctors
- Bisno AL. Pharyngitis. In: Mandell GLBJEaDR, ed. Mandell, Douglas and Bennett's principles and practice of infectious disease. Elsevier Churchill Livingstone.; 2009.
- MeReC. Sore Throat. MeReC Bulletin. 2006;17.
- Scottish Intercollegiate Guidelines Network. SIGN (2010) Management of sore throat and indications for tonsillectomy: a national clinical guideline. 117. April 2010.
Ref Type: Report
- Arroll B, Kenealy T, Falloon K. Are antibiotics indicated as an initial treatment for patients with acute upper respiratory tract infections? A review. N Z Med J. 2008;121:64-70.
- Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for sore throat. Cochrane Database Syst Rev. 2006;CD000023.
- Epstein MAaCDH. The Epstein-Barr Virus. In: Warrell DACTMFJDaBEJ, ed. Oxford textbook of medicine. Oxford University Press; 2003.
- Alcaide ML, Bisno AL. Pharyngitis and epiglottitis. Infect Dis Clin North Am. 2007;21:449-69, vii.
- Adams WG, Deaver KA, Cochi SL et al. Decline of childhood Haemophilus influenzae type b (Hib) disease in the Hib vaccine era. JAMA. 1993;269:221-226.
- Johannsen ECSRSaKKM. Epstein-Barr virus (infectious mononucleosis). In: Mandell GLBJEaDR, ed. Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia: Elsevier Churchill Livingstone; 2009.
- Glynn F, Fenton JE. Diagnosis and management of supraglottitis (epiglottitis). Curr Infect Dis Rep. 2008;10:200-204.
- Guldfred LA, Lyhne D, Becker BC. Acute epiglottitis: epidemiology, clinical presentation, management and outcome. J Laryngol Otol. 2008;122:818-823.
- Faulkner GC, Krajewski AS, Crawford DH. The ins and outs of EBV infection. Trends Microbiol. 2000;8:185-189.
- Little P, Williamson I. Sore throat management in general practice. Fam Pract. 1996;13:317-321.
- Cooper RJ, Hoffman JR, Bartlett JG et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med. 2001;134:509-517.
- Thomas M, Del MC, Glasziou P. How effective are treatments other than antibiotics for acute sore throat? Br J Gen Pract. 2000;50:817-820.
- Moghal NE, Hegde S, Eastham KM. Ibuprofen and acute renal failure in a toddler. Arch Dis Child. 2004;89:276-277.
- Kanabar D, Dale S, Rawat M. A review of ibuprofen and acetaminophen use in febrile children and the occurrence of asthma-related symptoms. Clin Ther. 2007;29:2716-2723.
- Petersen I, Johnson AM, Islam A, Duckworth G, Livermore DM, Hayward AC. Protective effect of antibiotics against serious complications of common respiratory tract infections: retrospective cohort study with the UK General Practice Research Database. BMJ. 2007;335:982.
- Bisno AL. Acute pharyngitis. N Engl J Med. 2001;344:205-211.
- Sirimanna KS, Madden GJ, Miles SM. The use of long-acting penicillin in the prophylaxis of recurrent tonsillitis. J Otolaryngol. 1990;19:343-344.
- Holm S, Henning C, Grahn E, Lomberg H, Staley H. Is penicillin the appropriate treatment for recurrent tonsillopharyngitis? Results from a comparative randomized blind study of cefuroxime axetil and phenoxymethylpenicillin in children. The Swedish Study Group. Scand J Infect Dis. 1995;27:221-228.
- Brook I, Hirokawa R. Treatment of patients with a history of recurrent tonsillitis due to group A beta-hemolytic streptococci. A prospective randomized study comparing penicillin, erythromycin, and clindamycin. Clin Pediatr (Phila). 1985;24:331-336.
- NICE. Respiratory tract infections: antibiotic prescribing. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care (NICE guideline). 2008. National Institute for Health and Clinical Excellence.
Ref Type: Report
- Spurling GK, Del Mar CB, Dooley L, Foxlee R. Delayed antibiotics for respiratory infections. Cochrane Database Syst Rev. 2007;CD004417.
- Herzon FS. Harris P. Mosher Award thesis. Peritonsillar abscess: incidence, current management practices, and a proposal for treatment guidelines. Laryngoscope. 1995;105:1-17.
- Kieff DA, Bhattacharyya N, Siegel NS, Salman SD. Selection of antibiotics after incision and drainage of peritonsillar abscesses. Otolaryngol Head Neck Surg. 1999;120:57-61.
- Haeggstrom A, Engquist S, Hallander H. Bacteriology in peritonsillitis. Acta Otolaryngol. 1987;103:151-155.
- Schwartz RH, Wientzen RL, Jr., Pedreira F, Feroli EJ, Mella GW, Guandolo VL. Penicillin V for group A streptococcal pharyngotonsillitis. A randomized trial of seven vs ten days' therapy. JAMA. 1981;246:1790-1795.
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)
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