Quebec gets a new protocol to standardize the treatment of pharyngitis and tonsillitis

Quebec’s National Institute of Excellence in Health and Social Services (INESSS) has recently published a set of guidelines and a collective prescription template for frontline professionals to standardize the treatment of group A streptococcal pharyngitis-tonsillitis (GAS) across the province.Services for detecting group A streptococcus (GAS), the main bacterium responsible for bacterial pharyngitis and tonsillitis, are already available, particularly at certain local service points through collective prescriptions, as well as at certain pharmacies across Quebec. However, these prescriptions vary from one administrative region to another.Meanwhile, the regulations in Bill 67, published in the Official Gazette on June 11, 2025, stipulate that pharmacists may now prescribe antibiotics to treat strep throat after a positive test.Based primarily on the optimal use guide for pharyngitis-tonsillitis, the guidelines:Enables the identification of individuals most likely to have a bacterial infection and who should be tested for GAS to promote optimal use of these tests;Specifies the specific management requirements associated with some of the detection tests available throughout the network (e.g., confirmation of a negative result);Includes clear direction for administering antibiotic therapy to individuals with a confirmed GAS infection, including the choice and dosage of the antibiotic and the procedure to follow in cases of a history of penicillin allergy.These guidelines apply to anyone three years of age or older who has had a sore throat for less than nine days, as well as at least one of the following signs and symptoms:tender or swollen anterior cervical lymph nodesexudate or swelling of the tonsilsfever above 100.4 F (38.0 C) (oral, rectal, or axillary temperature)After checking for signs of scarlet fever (erythematous and granular rash on the trunk resembling sandpaper, red and bumpy tongue, with or without a whitish coating), INESSS recommends healthcare professionals take a throat swab if these symptoms are present. If they are not present, clinicians should calculate the modified Centor score and check for any previous health conditions and medication history.If the modified Centor score is three or higher, or if at least one of the signs suggestive of scarlet fever is present, clinicians should perform a rapid GAS detection test or write the appropriate request for a culture, depending on local availability. For individuals residing in an indigenous community, if no GAS detection test is available AND the modified Centor score is three or higher, clinicians should initiate antibiotic therapy without taking a sample.If GAS infection is confirmed though a rapid test or culture, or if a patient resides in an Indigenous community, clinicians are encouraged to choose an antibiotic treatment from among those proposed in the protocol and to fully inform the person or their loved ones about the GAS infection.However, the guidelines do not apply to individuals for whom a throat swab is contraindicated (according to computerized care methods), or in the presence of at least one of the following signs or symptoms:fever with general malaisestridor or other signs of respiratory distress (e.g., tachypnea, dyspnea, etc.)pain or swelling in the neck, torticollis due to muscle spasm, stiffness in the neckvisible swelling in the pharynx, pharyngeal wall, soft palate, or floor of the oropharynxhypersalivation (sialorrhea)severe unilateral sore throatdysphagia with inability to drink or eatdysphonia or “presence of a muffled voice known as a hot potato voice” (speaking as if there were a hot object in the mouth)hematuriapurpuracutaneous petechiaetrismus (involuntary contraction of the jaw)Finally, INESSS reminds us that several situations require medical consultation, particularly if the person has already undergone three or more pharmacological treatments in the last year, or one treatment in the last four weeks, for strep throat; or if they show no improvement or a deterioration in their health after 48 to 72 hours of antibiotic treatment.This article has been translated from its original French and first appeared on our sister site Profession Santé.

Quebec gets a new protocol to standardize the treatment of pharyngitis and tonsillitis

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