1. Penicillin remains the drug of choice for Group A hemolytic streptococcus, the bacteria responsible for acute tonsillitis. A seven to 10 day prescription is recommended to prevent rheumatic heart disease and glomerulonephritis. Pen V.K. 250 mg qid is adequate. Begin with 24 hours of 500 mg qid.
   
   
   1. Pen V.K. 250 mg
      Disp 44 tablets
      Sig. ii p.o. qid x 4 doses then i p.o. qid x 9 days.
      
      
   2. Amoxicillin 250 mg
      Disp: 33 tablets
      Sig: ii p.o. tid x 3 doses, then i p.o. tid x 9 days
      
      
   3. Erythromycin is the drug of choice for penicillin allergic individuals.
      
      
2. Chronic/recurrent/persistent sore throat is a diagnostic challenge.
   
   
3. Sore throat is a diagnostic challenge. Unlike other algorithms in this series, sore throat 1 provides some diagnostic information. Sore throat 2 is a treatment algorithm.

Overview of Acute Sore Throat

An acute sore throat is a very common problem. Most upper respiratory tract viral infections begin with a sore throat. Unfortunately many Americans bring virtually every sore throat to their physician. The key is to correctly diagnose bacterial tonsillitis, treat this with antibiotics, correctly diagnose viral infections, not treat these with antibiotics and then recognize (preferably early) sore throat illnesses such as: tonsillitis, gonorrhea, peritonsillar abscess, mononucleosis, candidiasis, tumor etc.

The history is helpful, but the key to diagnosis is a good oral pharyngeal examination. Most physicians have inadequate lighting, and hence most pharyngeal exams are made with a floppy wooden tongue blade and the light of an otoscope.

While it is not necessary to have a coaxial, expensive fiberoptic headlight, you must have reasonable illumination. One or two wooden tongue blades usually will suffice. Then, you the physician, must have sufficient persistence to continue the examination until you have visualized the oral cavity, the lateral pharyngeal walls (including the tonsils) and the posterior pharyngeal wall. If the physical examination is well done, the correct diagnosis will follow. It is the hurried physician with a weak light and an uncooperative patient who misdiagnoses and mistreats.

Acute Sore Throat 2 is the controversial algorithm.

Our thinking is as follows: Cultures and rapid strep tests are not the end all for diagnosing tonsillitis. Given the large number of patients presenting with sore throat, cumulatively these tests are very expensive. It is therefore our recommendation that those pharyngitides which behave like a viral infection, be treated as such. Antibiotics play no role in their treatment and are a wasted health care dollar. They place the patient at unnecessary risk of allergic reaction to the antibiotics and expose an incredible number of normal oral organisms to antibiotics thereby promoting resistant organisms both in the patient and in the world.

While it may be true that it is easier to prescribe an antibiotic than to explain why you should not prescribe an antibiotic, most knowledgeable physicians will agree that antibiotics are not indicated for viral pharyngitis. If a viral pharyngitis diagnosis is made, and in fact, the patient has tonsillitis, the fever and the sore throat will continue and the patient will return on the second or third infectious day. The correct diagnosis will then be made. While the patient may have suffered an extra day or two of morbidity, no other harm has been done.

Classic streptococcal tonsillitis is readily diagnosed by history and examination. These patients are typically sicker, have a higher temperature, and they are more likely to have enlarged reactive cervical adenopathy. On examination the tonsils that are red and exudative and the posterior pharyngeal wall will appear normal. These patients have bacterial tonsillitis and penicillin remains the drug of choice.

Some patients fall in the middle, but this is a small percentage. The simplest is to assume that all of these have tonsillitis and to treat all with antibiotics. An alternative is to observe for 24 hours or use one of the rapid strep cultures or tests to assist in diagnosis.

Antibiotics are not indicated for the bacterial super infection of an upper respiratory tract viral illness. Steroids are not indicated in the treatment of either disease. There are an increasing number of bacterial tonsillitides resistent to penicillin. When such a case appears, reexamination is necessary to exclude peritonsillar abscess or one of the other causes of acute sore throat. Assuming the diagnosis remains tonsillitis, clindamycin has become the second line antibiotic. Penicillin and metronidazole remain an alternative.

In an appropriate setting with a very sick patient, a liter of Lactated Ringers goes a long way to make the patient feel better. The 600 mg 70kg male I.V. dose of clindamycin can be simultaneously administered, I.V. drip (20 minutes) NOT I.V. PUSH. Clindamycin is then given 300 mg p.o. q 6 hours for a 10 day treatment.

We have all been taught to treat tonsillitis for 7-10 days to obviate the sequelae of rheumatic heart disease and glomerulonephritis. The occurrence of post streptococcal glomerulonephritis has essentially disappeared. The incidence of post streptococcal rheumatic heart disease is reduced, compared with 50 years ago, but does still occur.

Lastly, if your patient has valvular heart disease, an artificial valve, or any condition which provides a nidus for infection, the tonsil should be swabbed for culture and sensitivity prior to instituting antibiotic therapy. Throat swabs are highly accurate if properly performed. Properly performed means swabbing across one tonsil, across the pharynx and across the other tonsil and swabbing sufficiently firmly that bacteria on and in the mucosa are captured by the swab. Too many swabbers simply dab up a little pharyngeal mucus and obtain insufficient material. Perhaps this should be renamed "a scrape biopsy".