What are the best antibiotics for recurring tonsillitis?

Best Antibiotics for Recurring Tonsillitis

For patients with recurring tonsillitis, amoxicillin-clavulanate or clindamycin are the preferred antibiotics due to their superior effectiveness against beta-lactamase-producing bacteria that may protect Group A Streptococcus from penicillin. 1

First-Line Treatment Options

When to Use Antibiotics

• Antibiotics are indicated only for bacterial tonsillitis, primarily Group A Streptococcal (GAS) infections
• Use Centor Criteria to determine likelihood of streptococcal pharyngitis 2:
  • Tonsillar exudates
  • Tender anterior cervical lymph nodes
  • Lack of cough
  • Fever
• Patients with 0-2 Centor criteria are unlikely to have GAS infection and do not require testing
• Those with 3-4 criteria should be tested with rapid antigen detection test (RADT) and/or throat culture 2

Recommended Antibiotics for Recurring Tonsillitis

1. First choice: Amoxicillin-clavulanate

   • More effective than penicillin in eradicating infection in recurrent cases 1
   • Addresses beta-lactamase-producing bacteria that may protect GAS 3
   • Dosage: Follow standard weight-based dosing for 10 days

2. For penicillin-allergic patients: Clindamycin

   • Superior clinical and microbiological effects compared to penicillin in recurring cases 1
   • Effective in preventing future episodes of acute pharyngo-tonsillitis 1
   • Dosage: 300-450 mg orally three times daily for 10 days 2

3. Alternative options:

   • Cephalosporins (for non-anaphylactic penicillin allergy) 2
   • Azithromycin or clarithromycin (with caution due to increasing resistance) 2, 4
     • Azithromycin dosage for pharyngitis/tonsillitis: 12 mg/kg once daily for 5 days (pediatric) 4

Duration of Treatment

• Complete the full 10-day course of antibiotics (except for azithromycin which is 5 days) even if symptoms improve before completion 2
• This is crucial to prevent complications such as acute rheumatic fever 2
• Patients should complete at least 24 hours of antibiotics before returning to school or work 2

Special Considerations for Recurring Cases

When to Consider Tonsillectomy

According to clinical practice guidelines, tonsillectomy should be considered if the patient has 5:

• ≥7 episodes of throat infection in the past year, OR
• ≥5 episodes per year for 2 consecutive years, OR
• ≥3 episodes per year for 3 consecutive years

Modifying Factors That May Favor Tonsillectomy

• Multiple antibiotic allergies/intolerance
• PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and adenitis)
• History of >1 peritonsillar abscess 5

Supportive Care

• Analgesics/antipyretics (acetaminophen or NSAIDs) for pain relief 2
• Cold liquids or ice chips for soothing throat irritation 2
• Avoid hot liquids and spicy foods that may irritate the throat 2

Common Pitfalls to Avoid

1. Using penicillin alone for recurring cases

   • Bacteriologic failure occurs in up to 20% of patients treated with penicillin 3
   • Beta-lactamase-producing bacteria can "shield" GAS by inactivating penicillin 3

2. Inadequate duration of treatment

   • Early discontinuation increases risk of recurrence and complications
   • Always complete the full course (10 days for most antibiotics, 5 days for azithromycin) 2

3. Unnecessary antibiotic use for viral pharyngitis

   • Viral causes should receive supportive care only, without antibiotics 2
   • Distinguish bacterial from viral causes using Centor criteria and appropriate testing

4. Ignoring increasing antibiotic resistance

   • Significant resistance to azithromycin and clarithromycin exists in some regions 2
   • Consider local resistance patterns when selecting antibiotics

By following these evidence-based recommendations, you can effectively manage recurring tonsillitis while minimizing complications and reducing the need for surgical intervention.