When should I consider prescribing antibiotics for a patient with tonsillitis, and which antibiotics are recommended?

When considering prescribing antibiotics for a patient with tonsillitis, you should assess their clinical presentation using scoring systems and consider their overall health status NICE CKS.

Considerations for Antibiotic Prescription:

• For a FeverPAIN score of 4 or 5, or a Centor criteria score of 3 or 4, or if Group A Streptococcus (GAS) has been confirmed by rapid antigen testing, consider an immediate antibiotic prescription or a back-up antibiotic prescription NICE CKS.


• If the patient is systemically very unwell, has symptoms and signs of a more serious illness or condition, or is at high-risk of complications, offer an immediate antibiotic prescription NICE CKS.


• For a FeverPAIN score of 2 or 3, consider no antibiotic prescription or a back-up antibiotic prescription NICE CKS. This decision should take into account that antibiotics make little difference to how long symptoms last (shortening them by about 16 hours on average), most people feel better after 1 week with or without antibiotics, the unlikelihood of complications if antibiotics are withheld, and possible adverse effects like diarrhoea and nausea NICE CKS.


• Do not offer an antibiotic prescription for a FeverPAIN score of 0 or 1, or a Centor score of 0, 1, or 2 NICE CKS. Advise that an antibiotic is not needed and they should seek medical help if symptoms worsen rapidly or significantly, do not start to improve after 1 week, or they become systemically very unwell NICE CKS.


• For vulnerable people (e.g., infants, very old people, immunosuppressed/immunocompromised individuals), or those taking certain medications like disease-modifying anti-rheumatic drugs (DMARDs) or carbimazole, consider prescribing an antibiotic NICE CKS.

Recommended Antibiotics:

• First-line: Prescribe phenoxymethylpenicillin NICE CKS.


• For people with penicillin allergy: Prescribe clarithromycin NICE CKS.


• For a pregnant woman with penicillin allergy: Prescribe erythromycin NICE CKS.

Back-up (Delayed) Prescriptions:

• If a back-up antibiotic prescription is given, advise the patient that an antibiotic is not needed immediately NICE CKS.


• The back-up antibiotic should be used if symptoms do not start to improve within 3 to 5 days, or if they worsen rapidly or significantly at any time NICE CKS.


• Provide safety-netting advice, including how long symptoms are likely to last, what to do if symptoms get worse, and when to seek medical advice again NICE NG63.