Treatment Guideline Chart
Patients with group A beta-hemolytic streptococcal pharyngitis have classic symptoms of tonsillar swelling/exudates, tender anterior cervical lymphadenopathy, with no cough but with fever of >38ºC.
Clinical features suggestive of a viral etiology are conjunctivitis, absence of fever, coryza, cough, diarrhea, anterior stomatitis, hoarseness, discrete ulcerative lesions, rhinorrhea and viral exanthem and/or enanthem.
Antibiotics will not be needed for every patient that presents with sore throat but it should not be withheld if the clinical condition is severe or group A beta-hemolytic streptococcus is suspected.

Tonsillopharyngitis%20-%20acute Signs and Symptoms


  • Acute infection of the pharynx, palatine tonsils, or both
  • Also called strep throat, acute tonsillitis, pharyngitis or adenotonsillitis
  • One of the most common diseases seen in primary care


  • Main cause of acute tonsillopharyngitis
  • Double-stranded DNA viruses (human adenovirus, Epstein-Barr virus), single-stranded RNA viruses (influenza, para-influenza, rhinovirus, enteroviruses, Coxsackie virus, coronaviruses, respiratory syncytial virus [RSV], human meta-pneumo-virus) and retroviruses (human immunodeficiency virus [HIV]) are among the viral causes
  • Responsible for about 5-15% of clinic consultations for acute sore throat in adults 
  • Most commonly caused by Gram-positive cocci known as Streptococcus pyogenes
    • This organism exhibits beta-hemolysis on blood agar plates
    • Belongs to group A Lancefield classification system for beta-hemolytic strep infection
  • Other bacterial causes include group C and G Streptococci, Staphylococcus aureus, Haemophilus influenzae, Nocardia, Corynebacteria and Neisseria gonorrhoeae
Mode of Transmission
  • Spreads through person-to-person contact, usually through saliva or nasal secretions from an infected person
    • Primary reservoir of group A Streptococcus are the humans
  • Easily transmitted in the schools, day care centers and military training facilities
  • Transmission via food is rare and if transmission happens, it is most of the time due to improper handling of food
  • Pets and the use of household items such as plates and toys cannot transmit the disease

Signs and Symptoms

Clinical Features Suggestive of a Viral Etiology

  • Absence of fever
  • Conjunctivitis
  • Coryza
  • Cough
  • Diarrhea
  • Hoarseness
  • Malaise or fatigue
  • Rhinorrhea
  • Anterior stomatitis
  • Discrete ulcerative lesions
  • Viral exanthem and/or enanthem

Clinical Features Suggestive of Group A Beta-Hemolytic Streptococcal (GABS) Pharyngitis

  • The incubation period is approximately 2-7 days

Classic Symptoms

  • Tonsillar swelling/exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough
  • Fever >38°C

Other Features

  • History of exposure
  • Sudden onset of sore throat
  • Pain on swallowing
  • Petechiae on soft palate (“doughnut” lesions)
  • Scarlet fever rash
  • Beefy red, swollen uvula
  • Tonsillopharyngeal inflammation and erythema with or without exudates
  • Headache
  • Nausea and vomiting (N/V)
  • Abdominal pain
  • Malodorous breath

Red Flags Requiring Assessment for Urgent Care and Hospitalization

  • Assess for signs and symptoms of airway obstruction needing urgent management
  • Respiratory distress: Chest retractions, cyanosis, moderate-severe dyspnea, increased respiratory rate, shallow breathing, difficulty swallowing, choking, foreign body inhalation, drooling, dysphonia
  • Altered mental state, decreased consciousness level, severe lethargy, excessive sleepiness with difficulty to stay awake, unresponsiveness
  • Changes in everyday activity: Refusal to eat and markedly reduced activity
  • Signs of dehydration, no urine output for >12 hours, vomiting
  • Meningeal signs: Stiff neck, persistent vomiting, severe headache
  • Petechial or purpuric rash

Risk Factors

  • Commonly infects children aged 5-15 years old and rare in <3 years old; parents of school-aged children and other adults who are in close contact with the infected individual
  • Crowded places (eg day care centers, school, military barracks)
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