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 ¹.

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 ¹.
• 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 ¹.
• For a FeverPAIN score of 2 or 3, consider no antibiotic prescription or a back-up antibiotic prescription ¹. 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 ¹.
• Do not offer an antibiotic prescription for a FeverPAIN score of 0 or 1, or a Centor score of 0, 1, or 2 ¹. 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 ¹.
• 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 ¹.

Recommended Antibiotics:

• First-line: Prescribe phenoxymethylpenicillin ¹.
• For people with penicillin allergy: Prescribe clarithromycin ¹.
• For a pregnant woman with penicillin allergy: Prescribe erythromycin ¹.

Back-up (Delayed) Prescriptions:

• If a back-up antibiotic prescription is given, advise the patient that an antibiotic is not needed immediately ¹.
• 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 ¹.
• 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 ⁴.