Acute pharyngitis

– Acute inflammation of the tonsils and pharynx. The majority of cases are of viral origin and do not require antibiotherapy. Group A streptococcus is the main bacterial cause, and mainly affects children age 3 to 14 years.
– Acute rheumatic fever, a serious late complication of Group A streptococcal pharyngitis (GAS), can be prevented with antibiotherapy.
– One of the main objectives in assessing acute pharyngitis is to identify patients requiring antibiotherapy.

Clinical features

– Features common to all types of pharyngitis: throat pain and dysphagia (difficulty swallowing), with or without fever.

– Specific features, depending on the cause:

Common forms:

• Erythematous (red throat) or exudative (red throat and whitish exudate) pharyngitis: since this appearance is common to both viral and GAS pharyngitis, a clinical score that allows identification of children at high risk for GAS should be used. The Joachim score diminishes empiric antibiotic use in settings where rapid testing for GAS is not available.

Joachim score


≤ 35 months


36 to 59 months


≥ 60 months


Signs of bacterial infection

One point for each

Total number
of bacterial signs

Tender cervical node


Petechiae on the palate

Abdominal pain

Sudden onset (< 12 hours)

Take age value (1, 2 or 3) and add it to the number of bacterial signs above =

Signs of viral infection

One point for each

Total number
of viral signs


Coryza (runny nose)


Subtract the number of viral signs to obtain the score =

In patients over 14 years, the probability of GAS pharyngitis is low. Infectious mononucleosis (IM) due to the Epstein-Barr virus should be suspected in adolescents and young adults with extreme fatigue, generalized adenopathy and often splenomegaly.

Erythematous or exudative pharyngitis may also be associated with gonococcal or primary HIV infection. In these cases, the diagnosis is mainly prompted by the patient's history.

• Pseudomembranous pharyngitis (red tonsils/pharynx covered with an adherent greyish white false membrane): see Diphtheria.
• Vesicular pharyngitis (clusters of tiny blisters or ulcers on the tonsils): always viral (coxsackie virus or primary herpetic infection).
 Ulcero-necrotic pharyngitis: hard and painless syphilitic chancre of the tonsil; tonsillar ulcer soft on palpation in a patient with poor oral hygiene and malodorous breath (Vincent tonsillitis).

– Local complications:
Peritonsillar abscess: fever, intense pain, hoarse voice, trismus (limitation of mouth opening), unilateral deviation of the uvula.


– In all cases: paracetamol PO, see Fever, Chapter 1.

– Joachim score ≤ 2: viral pharyngitis, which typically resolves within a few days (or weeks, for IM): no antibiotherapy.

– Joachim score ≥ 3: antibiotherapy for GAS pharyngitis:

• If single-use injection equipment is available, benzathine benzylpenicillin is the drug of choice as streptococcus A resistance to penicillin remains rare; it is the only antibiotic proven effective in reducing the incidence of rheumatic fever; and the treatment is administered as a single dose.
benzathine benzylpenicillin IM
Children under 30 kg (or under 10 years): 600 000 IU single dose
Children 30 kg and over (or 10 years and over) and adults: 1.2 MIU single dose

• Penicillin V is the oral reference treatment, but poor adherence is predictable due to the length of treatment.
phenoxymethylpenicillin (penicillin V) PO for 10 days
Children under 1 year: 125 mg 2 times daily
Children 1 to < 6 years: 250 mg 2 times daily
Children 6 to < 12 years: 500 mg 2 times daily
Children 12 years and over and adults: 1 g 2 times daily

• Amoxicillin is an alternative and the treatment has the advantage of being relatively short. However, it can cause adverse skin reactions in patients with undiagnosed IM and thus should be avoided when IM has not been excluded.
amoxicillin PO for 6 days
Children: 25 mg/kg 2 times daily
Adults: 1 g 2 times daily

• Macrolides should be reserved for penicillin allergic patients as resistance to macrolides is frequent and their efficacy in the prevention of rheumatic fever has not been studied. 
azithromycin PO for 3 days
Children: 20 mg/kg once daily (max. 500 mg daily)
Adults: 500 mg once daily

– Gonococcal or syphilitic pharyngitis: as for genital gonorrhoea (Chapter 9) and syphilis (Chapter 9).

– Diphtherial pharyngitis: see Diphtheria.

– Vincent tonsillitis: penicillin V as above.

– Peritonsillar abscess: refer for surgical drainage.