Short report
Antibiotics for tonsillitis: should the emergency
1
Department of Paediatrics,
Northwick Park Hospital,
London North West Healthcare
NHS Trust, London, UK
2
Department of Microbiology,
Northwick Park Hospital,
London North West Healthcare
NHS Trust, London, UK
3 and coded with acute tonsillitis in the ED over a
Department of Research and
Development, Northwick Park
Hospital, London North West
Healthcare NHS Trust,
London, UK
Correspondence to
Dr Kamil Kanji,
Department of Paediatrics,
Northwick Park Hospital,
London North West
Healthcare NHS Trust,
London HA1 3UJ, UK;
kamil.kanji@gmail.com
Received 12 April 2016
Revised 31 May 2016
Accepted 8 June 2016
Published Online First
29 June 2016
To cite: Kanji K, Saatci D,
Rao GG, et al. J Clin Pathol
2016;69:834836.
834
department emulate general practice?
Kamil Kanji,1 Defne Saatci,1 Gopal G Rao,2 Priya Khanna,2 Paul Bassett,3
Bhanu Williams,1 Murtuza Khan1
ABSTRACT
Objectives To determine whether antibiotics are
prescribed appropriately for acute tonsillitis in an
emergency department (ED).
Methods Cross-sectional observational study in large
district general hospital in London. Patients diagnosed
care professionals that antibiotics are helpful for
3-month period in 2015. Medical records were reviewed
for Centor criteria, which is a clinical scoring system to
guide antibiotic prescribing in UK general practice. Drug
charts were reviewed for the specic antibiotic(s)
prescribed, and throat swab (TS) cultures were recorded.
Results 273/389 patients with tonsillitis were analysed
186 children, 87 adults. Exclusions were missing
patient records (86), patients had/awaiting tonsillectomy
(22), receiving antibiotics (6) and immunocompromised
(2). Centor score (CS) was not recorded for any patient.
Based on derived CS from documented signs/symptoms,
antibiotics were prescribed inappropriately to 196/273
patients (80%; 95% CI 74% to 85%) including broad-
spectrum antibiotics to 25%. These included co-
amoxiclav (18%), amoxicillin (6%), azithromycin (0.5%)
and ceftriaxone (0.5%). TSs were taken in 66/273(24%)
patients; 10/66 were positive for group A streptococcus
(GAS). However, 48/56 GAS negative patients were
prescribed antibiotics.
Conclusions CS was not being used in the ED to
guide antibiotic prescribing for acute tonsillitis. Antibiotic
prescribing was based on clinical judgement. Based on
derived CS (<3), 80% of patients were inappropriately
prescribed antibiotics, particularly broad-spectrum
antibiotics. Further studies need to assess use of CS to
guide antibiotic prescription in ED. TSs were commonly
performed in the ED but did not either improve
diagnosis or guide antibiotic prescription.
INTRODUCTION
Acute tonsillitis is a frequent cause of visits and
antibiotic prescribing in primary care.1 The major-
ity of cases are viral and the symptoms of tonsillitis,
including sore throat, fever and headache, typically
pass in 34 days.2 The most common bacterial
cause of acute tonsillitis is group A streptococcus
(GAS), which accounts for 10%15% of acute ton-
sillitis.3 GAS can also cause acute otitis media
(AOM), peritonsillar abscess (quinsy) and, more
rarely, septicaemia, empyema and meningitis.
Therefore, appropriate and timely treatment is
important. Antibiotics confer relative benets in
preventing AOM and quinsy but the numbers
needed to treat are very high. The mean annual
incidence of hospital admission quinsy is low, at
1.66 per 10 000.4 The non-suppurative
Kanji K, et al. J Clin Pathol 2016;69:834836. doi:10.1136/jclinpath-2016-203808
complications, including acute glomerulonephritis
and rheumatic fever, are now rare.4
Whether or not antibiotics are used, 85% of
patients with acute tonsillitis are free of symptoms
after 1 week.5 Prescribing antibiotics may give
patients and their families the message from health-
most infections and they may attribute symptom
resolution to antibiotics (National Institute for
Health and Care Excellence (NICE) guidance,
2008).4 Overuse of antibiotics is contributing to
the global threat of antibiotic resistance.6
Throat swabs and rapid antigen detection tests
(RADTs) are not routinely used in UK general prac-
tice; primary care clinicians rely on symptoms and
signs to decide on initial treatment with antibio-
tics.4 NICE guidance states that immediate treat-
ment with antibiotics should be offered to patients
who have three or more Centor score: history of
fever, tonsillar exudate, tender enlarged cervical
lymph nodes and absence of cough.4 It also states
that, if no antibiotic is prescribed, the patient
should be offered (a) reassurance that antibiotics
are not needed immediately and may have side
effects, and (b) a clinical review, should the condi-
tion worsen or become prolonged. The patient may
be advised to collect a delayed prescription if the
symptoms do not settle with the expected course of
the illness or if the symptoms worsen. The Centor
score has not been validated for use in the emer-
gency departmentthere is no clear guidance on
antibiotic prescribing.
Centor score, used as a tool to assess the absence
of GAS, was originally developed for adults.7
McIsaac et al8 developed modied Centor score
(+1 for age<14, 0 for age 1544 and 1 for age
45), which takes into account higher rates of
streptococci in 515 year olds. Roggen et al9
assessed the use of modied Centor score in patients
age 216 attending paediatric emergency depart-
ment in Belgium with a sore throat and found it to
be insensitive to evaluate the presence of GAS.
However, Fine et al10 analysed data collected in the
USA from 206 870 patients 3 years or older present-
ing with a painful throat to a national retail health
chain. They validated the Centor and McIsaac
scores in identifying patients with GAS pharyngitis.
Orda et al11 in a study of paediatric patients pre-
senting with a sore throat to a remote Australian
emergency department found that clinical judge-
ment and Centor score were inadequate tools for
clinical decision making and that adjunctive point of
care testing with a rapid antigen detection test for
GAS provided sufcient accuracy to guide antibiotic
prescription.
 Short report

Table 1 Prescription of antibiotic by group, according to Centor score (n=273)

Children <16 years (n=186), n (%; 95% CI) Adults 16 years (n=87), n (%; 95% CI) Total (n=273), n (%; 95% CI)

Centor score
0 2/2 (100%) 7/13 (54%) 9/15 (60%)
1 44/76 (58%) 42/43 (98%) 86/119 (72%)
2 78/85 (92%) 23/27 (85%) 101/112 (90%)
3 21/21 (100%) 4/4 (100%) 25/25 (100%)
4 1/2 (50%) 0/0 (0%) 1/2 (50%)
<3 criteria 124/163 (76%; 69% to 82%) 72/83 (87%; 78% to 93%) 196/246 (80%; 74% to 85%)

The Primary Care Streptococcal Management (PRISM) study Statistical analysis: The main outcome was categorical in
in 2013 suggested that conventional clinical scoring systems nature, and was summarised by the number and percentage of
such as the Centor score might not be reliable in identifying responses in each category. Additionally, the uncertainty in the
streptococcal throat infections..12 This study also suggested that estimated percentage values was indicated by calculating corre-
the speed of presentation and severity of tonsillar inammation sponding CIs using the exact binomial method.
and fever might be the most important features to identify
streptococcal infection. These scores were then incorporated
RESULTS
into a modied ve-point clinical scoring system called
Of the 389 patients diagnosed with acute tonsillitis at the emer-
FeverPAIN: fever during the last 24 hours, pus on the tonsils,
gency department within the 3-month period, 86 patient
attends rapidly (<3 days duration), inamed tonsils and no
records were missing, duplicated or mislabelled; 22 patients had
cough or runny nose.
or were awaiting tonsillectomy; six were taking antibiotics; and
The 2014 PRISM study compared the management of sore
two were immunocompromised. Therefore, 273 patients were
throats in primary care using FeverPAIN score, RADTs and
analysed186 children and 87 adults.
delayed antibiotic prescribing (control group).13 They found
Patients diagnosed with acute tonsillitis presented with fever
that RADTs and FeverPAIN both reduced antibiotic prescribing
(88%), tonsillar exudate (40%), tender cervical lymph nodes
compared with a delayed antibiotic prescribing strategy.
(8%) and absence of cough (18%). In total, 245/273 (90%)
However, using a RADT in addition to clinical score provided
patients diagnosed with acute tonsillitis presented with <3
no clear benet over using clinical score alone. FeverPAIN has
Centor score and 28/273 (10%) patients presented with 3
not yet been validated for use in primary care. NICE still recom-
Centor score.
mends using Centor score in primary care to determine the like-
Table 1 shows the prescription of antibiotic by group, according
lihood of a sore throat being due to a bacterial infection.
to the Centor score. Antibiotics were prescribed to 196/246 patients
Few studies have assessed the management of sore throats in
(80%; 95% CI 74% to 85%) diagnosed with acute tonsillitis in the
UK emergency departments, which is an important point of
emergency department presenting with <3 Centor score.
access for patients.
Figure 1 shows the distribution of antibiotics prescribed to
treat acute tonsillitis. Overall, 216/273 (79%) patients diagnosed
OBJECTIVES with acute tonsillitis were prescribed antibiotics. Penicillin V was
The objective was to determine whether antibiotics are pre-
scribed appropriately for acute tonsillitis in the emergency
department, according to Centor score developed for use in
primary care and throat swab culture results.

METHODS
Cross-sectional observational study at Northwick Park Hospital,
London, North West Healthcare NHS Trust.
Inclusion: All patients diagnosed and coded with acute tonsil-
litis in the emergency department, Northwick Park Hospital
over a 3 month period in 2015.
Exclusion: More than ve episodes of tonsillitis in last year,
immunosuppression, heart valve disease, rheumatic fever,
episode of tonsillitis treated with antibiotics in previous 15 days,
tonsillectomy, mislabelled diagnoses, missing or duplicated
notes.
Data collection: Medical records were reviewed for Centor
criteria, which is a clinical scoring system for use in UK general
practice to give an indication of the likelihood of a sore throat
being due to bacterial infection. The results of throat swab cul-
tures were recorded and drug charts were reviewed for the spe-
cic antibiotic(s) prescribed.
Main outcome measure: Percentage of patients prescribed
antibiotics inappropriately, according to Centor score (<3) and Figure 1 Breakdown of antibiotics prescribed to treat acute tonsillitis
negative throat swab culture at 48 hours. (n=216).
Kanji K, et al. J Clin Pathol 2016;69:834836. doi:10.1136/jclinpath-2016-203808 835
 Short report
prescribed in 66% of cases (73% to children and 54% to
adults). Clarithromycin was prescribed in cases where a penicil-
lin allergy was documented, in line with the Trust Antibiotic
Policy. Broad-spectrum antibiotics were prescribed in 25% of
cases. These included co-amoxiclav (18%), amoxicillin (6%),
azithromycin (0.5%) and ceftriaxone (0.5%).
Throat swabs were taken in 66/273 (24%) patients. Of these,
10/66 were positive for GAS and were prescribed antibiotics.
Antibiotics were also prescribed to 48/56 GAS negative patients,
38/44 children (86%; 95% CI 73% to 95%) and 10/12 adults
(83%; 95% CI 52% to 98%).
DISCUSSION
Centor score was not being used in the emergency department
to guide antibiotic prescription for acute tonsillitis. Antibiotic
prescribing was based on clinical judgement. In assessing
whether Centor score had been used, the number of signs/symp-
toms documented had to be counted. Only 27 (10%) patients
presented with 3 Centor score, whereas the PRISM study in
2013 found that 43% of patients with a sore throat in primary
care presented 3 Centor score.11 Based on the derived Centor
score, 196/246 patients (80%; 95% CI 74% to 85%) were
inappropriately prescribed antibiotics (<3 Centor score). There
was considerable overprescription of antibiotics, particularly
broad-spectrum antibiotics. A broad-spectrum antibiotic was
prescribed in 25% of cases despite GAS being uniformly suscep-
tible to penicillin V. These included co-amoxiclav (18%), amoxi-
cillin (6%), azithromycin (0.5%) and ceftriaxone (0.5%).
Throat swabs were taken inappropriately in 66/273 (24%)
patients. Of these, only 10/66 were positive for GAS. However,
antibiotics were prescribed to 48 of the 56 GAS negative patients.
The GAS carriage rate (15%) in the emergency department was
comparable to healthy carrier rates reported in primary care,
20%30% in children and 5%15% in adults.14 Furthermore,
the cost of taking throat swab cultures was 458.03, which
included materials and laboratory time.i Throat swab cultures did
not guide antibiotic prescribing for acute tonsillitis as they had a
turnaround time of 3 days and, therefore, should not have been
taken in patients presenting with a sore throat.1
In conclusion, this retrospective study points to overuse of
antibiotics and misuse of broad-spectrum antibiotics in the man-
agement of sore throats in our emergency department, which
contribute to antibiotic resistance. Further research is needed to
assess the applicability of clinical scoring systems such as Centor
in the emergency department to guide antibiotic prescribing.
Furthermore, this study showed that despite NICE guidance for
throat swabs not to be carried out routinely in the management
of sore throats, they were performed frequently and did not
either conrm diagnosis or guide antibiotic prescribing.
What is already known about this area?
Acute tonsillitis is a frequent cause of visits in primary care.
National Institute for Health and Care Excellence (NICE)
guidance for primary care states that immediate treatment
with antibiotics should be offered to patients who have
three or more Centor score.
The Centor score has not been validated for use in the
emergency department.
i
Unit price 6.94 (Northwick Park Hospital Pathology Department).
836
What will this study add to the literature?
This retrospective study points to overuse and misuse of
antibiotics in the management of sore throats in our emergency
department, which contribute to antibiotic resistance. Further
research is needed to assess the applicability of clinical scoring
systems such as Centor in the emergency department to guide
antibiotic prescribing. Furthermore, this study showed that
despite NICE guidance for throat swabs not to be carried out
routinely in the management of sore throats, they were
performed frequently and did not either conrm diagnosis or
guide antibiotic prescribing.
Handling editor Slade Jensen
Acknowledgements KK would like to thank his parents, Najmi and Nazneen, for
critically reviewing the manuscript.
Contributors KK initiated the study, conducted the literature review and
implemented the study with the guidance of DS, GGR, PK, BW and MK. PB
conducted the statistical analysis. All authors edited and approved the nal
manuscript.
Competing interests None declared.
Ethics approval Ethical approval was not required (National Research Ethics
Service).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement Data were used from the emergency department
medical records, subject to condentiality and usual norms for access.
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