What is the next step in managing persistent tonsillitis in a 2-year-old child that has not responded to Penicillin (Pen V) and Co-amoxiclav (Co-amox)?

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Last updated: March 14, 2025 • View editorial policy

From the Guidelines

For persistent tonsillitis in a 2-year-old not responding to penicillin V and co-amoxiclav, I recommend referral to an ENT specialist for evaluation and possible tonsillectomy consideration, as suggested by the most recent clinical practice guideline update 1. Before referral, a throat culture should be obtained to identify potential resistant organisms or beta-lactamase producing bacteria. Some key points to consider in the management of this condition include:

  • Alternative antibiotic options, such as clindamycin (10-13 mg/kg/dose three times daily for 10 days) or azithromycin (10 mg/kg on day 1, then 5 mg/kg daily for 4 more days), may be considered if the child has no allergies to these medications 1.
  • Recurrent tonsillitis in young children may indicate either antibiotic resistance, poor compliance with medication, or an underlying immune issue.
  • Supportive care is also important, including:
    • Ensuring adequate hydration
    • Using acetaminophen or ibuprofen for pain and fever
    • Considering warm salt water gargles if the child is able
  • If symptoms include difficulty breathing, drooling, or severe throat pain with limited neck movement, immediate medical attention is required as these could indicate peritonsillar abscess or other complications requiring urgent intervention. The clinical practice guideline update also emphasizes the importance of assessing the child for modifying factors that may favor tonsillectomy, such as multiple antibiotic allergies/intolerance, PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis), or history of peritonsillar abscess 1, 2. It is essential to note that the decision to proceed with tonsillectomy should be made on a case-by-case basis, taking into account the individual child's circumstances and the potential benefits and risks of the procedure, as outlined in the clinical practice guideline update 3.

From the Research

Next Steps in Managing Persistent Tonsillitis

The next step in managing persistent tonsillitis in a 2-year-old child that has not responded to Penicillin (Pen V) and Co-amoxiclav (Co-amox) could involve considering alternative antibiotic treatments.

  • Cefixime has been shown to be effective in treating bacterial pharyngitis and tonsillitis in children, with studies indicating that a 5-day course of cefixime is at least as effective as a 10-day course of penicillin V 4, 5, 6.
  • Another option could be cefuroxime axetil, which has been found to be effective in treating streptococcal tonsillopharyngitis in children, with a 5-day course being at least as effective as a 10-day course of penicillin V 7.
  • Cefetamet pivoxil is also an effective treatment alternative for pharyngitis/tonsillitis in children and adults, offering the advantage of a shorter regimen and a low incidence of adverse effects 8.

Considerations for Treatment

When considering the next steps in treatment, it is essential to take into account the child's age, the severity of the infection, and any potential allergies or sensitivities to antibiotics.

  • The studies suggest that cefixime and cefuroxime axetil are safe and effective in children, with minimal adverse effects 4, 5, 7, 6.
  • The choice of antibiotic should be based on the specific needs of the child and the severity of the infection, as well as any local resistance patterns.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.