Acute sore throat / Tonsillitis

Case Definition:

An acute, usually viral infection of the palatine tonsils. Usually bilateral. Secondary bacterial infection can occur. Can be associated with cervical lymphadenopathy, always consider infectious mononucleosis.


Diagnostic criteria:

Sore throat, pain on swallowing, otalgia and dysphagia. Pyrexial and systemically unwell. Trismus may be present. Generalised erythema of the tonsils can be large and swollen. Follicles may be evident on the tonsil surface and an exudate may be present. Lymphadenopathy is often present affecting the cervical glands. Consider diphtheria (rare) if there is a membranous exudates over the tonsils or when severe airway obstruction is evident.


Specimens to be collected:

  • Throat swab for bacterial culture
  • Monospot test (serum) if appropriate



NICE guidance on URTI indicates that antibiotics are not routinely indicated for category A patients with acute sore throat/tonsillitis. 90% of patients’ symptoms resolve in 7 days without antibiotics and the pain of sore throat is only reduced by 16 hours. 90% of patients with Epstein-Barr Virus (EBV) will develop a rash or Stevens-Johnson syndrome when given amoxicillin so penicillin V should always be used in preference when treating acute exudative tonsillitis. Acute EBV infection may present with exudative tonsillitis so consider checking a Monospot test. If diphtheria suspected contact the ENT consultant and consultant microbiologist.



1st line oral/iv antibiotics

Penicillin allergy
(see explanatory notes)

Minor to moderate infection

Review doses in renal impairment

Antibiotics not routinely indicated (see above)

PENICILLIN V 500mg po qds for 10 days

Antibiotics not routinely indicated (see above)

CLARITHROMYCIN 250-500mg po bd  for 5 days


Moderate to severe life threatening infection 

Review doses in renal impairment

(NB. increase to 2.4g qds if severe systemic toxicity) for 10 days
CLARITHROMYCIN 500mg bd po/iv, for 5 days
IV to Oral Switch (explanatory notes

PENICILLIN V 500mg po qds

Typical duration: 10 days

CLARITHROMYCIN 250-500mg po bd

Typical duration: 5 days

Last reviewed:23/04/14

For guidance on the administration of intravenous antibiotics
click here (GHNHSFT intranet only)