Tonsillitis, pharyngitis. See SIGN guideline.
See also pharyngitis treatment.
FeverPAIN scoring system – possibly better than Centor at avoiding antibiotics. For primary care settings, children over 3 and adults.
- Fever in past 24hrs
- Purulent tonsils
- Attends rapidly (ie symptoms <=3 days)
- Severe tonsil Inflammation
- No cough/coryza
3 points gives 40-50% risk of strep, so treat at 4 points, consider delayed antibiotics for 3 points. Not for under 3s, and beware worsening after 3 days which might indicate more severe infection. [PRISM study 2014]
Centor and McIsaac scores to predict group A streptococcal pharyngitis. One point for each of the following:
- absence of cough,
- presence of tonsillar exudates, and
- swollen, tender anterior cervical nodes [my emphasis].
Centor score is sum (0-4). The McIsaac score (1998) is an adjustment of +1 to account for the increased incidence of GAS in children <15yr and -1 for decreased incidence in those 45+ years. CDC advises treat empirically at score 3+ or at score 2 if rapid testing positive.
Original studies used small samples, but national US study confirmed validity in 65 000 patients aged 3-14yrs presenting to primary care. For children, GAS positive rates were:
- 14% for McIsaac 1
- 23% for 2
- 37% for 3
- 55% for 4
AUC was 0.71 for McIsaac score across all ages.
Other clinical decision rules include:
- the WHO rule (purulent oropharyngeal exudate and tender enlarged anterior cervical lymph nodes = bacterial pharyngitis);
- the Abu Reesh rule (purulent oropharyngeal exudate or tender enlarged anterior cervical lymph nodes = bacterial pharyngitis); and
- the Steinhoff rule (absence of rash, absence of moderate or severe rhinitis, presence of tender enlarged anterior cervical lymph nodes).
Rapid antigen test performs better, 85% sensitivity (similar to Abu Reesh rule) but much better PPV (48%).