What is the approach to assessment and treatment plan for tonsillitis or recurring strep throat?

Assessment and Management of Tonsillitis and Recurrent Strep Throat

For patients with recurrent throat infections, clinicians should recommend watchful waiting if there have been <7 episodes in the past year, <5 episodes per year in the past 2 years, or <3 episodes per year in the past 3 years, with tonsillectomy reserved for those meeting specific frequency criteria with documented symptoms. 1

Diagnostic Approach

Clinical Assessment

• Evaluate for key clinical features:
  • Temperature ≥38.3°C (101°F)
  • Cervical adenopathy
  • Tonsillar exudate
  • Absence of cough (suggests bacterial rather than viral etiology)

Laboratory Testing

• Rapid Antigen Detection Tests (RADTs) should be considered for patients with high likelihood of streptococcal infections (3-4 Centor criteria) 2
• Document each episode in the medical record, including:
  • Symptoms
  • Physical findings
  • Test results (rapid antigen or culture)
  • Days of school/work absence
  • Quality of life impact

Treatment Algorithm

Acute Tonsillitis/Pharyngitis

1. For confirmed Group A Streptococcal (GAS) infection:

   • First-line therapy: Penicillin V

     • Adults: 250 mg three times daily for 10 days 2
     • Children: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 2

   • For penicillin-allergic patients:

     • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 2, 3
     • Clindamycin: 300-450 mg orally three times daily for 10 days 2

2. For viral tonsillitis (70-95% of cases): 4

   • Symptomatic relief with analgesics:
     • Ibuprofen: 400mg every 6-8 hours for adults
     • Acetaminophen: 500-1000mg every 4-6 hours for adults
   • Adequate hydration
   • Rest

Recurrent Strep Throat Management

1. Watchful waiting: (Strong recommendation)

   • For patients with <7 episodes in the past year
   • For patients with <5 episodes per year in the past 2 years
   • For patients with <3 episodes per year in the past 3 years 1

2. Consider tonsillectomy: (Optional)

   • For patients with ≥7 episodes in the past year
   • For patients with ≥5 episodes per year for 2 years
   • For patients with ≥3 episodes per year for 3 years
   • Each episode must be documented with at least one of: fever ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 1

3. Consider tonsillectomy with modifying factors:

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

4. For treatment-resistant recurrent cases:

   • Consider alternative antibiotics:
     • Amoxicillin with clavulanate has shown superior efficacy compared to penicillin in recurrent cases 5, 6
     • Clindamycin has demonstrated effectiveness in eradicating GAS from tonsils and preventing future episodes 5

Special Considerations

Documentation Requirements

• Medical record documentation is essential for each episode:
  • Symptoms and physical findings
  • Laboratory confirmation
  • Treatment provided
  • Response to therapy 1

Antibiotic Duration

• Treatment should continue for a minimum of 10 days for GAS pharyngitis to prevent acute rheumatic fever 7
• Complete the full course even if symptoms resolve earlier

Potential Complications to Monitor

• Peritonsillar abscess
• Acute rheumatic fever
• Acute glomerulonephritis
• Scarlet fever 4

Pitfalls and Caveats

1. Avoid unnecessary tonsillectomy:

   • Benefits of tonsillectomy are modest and generally limited to the first year post-surgery 1
   • Watchful waiting does not mean inaction—continue to monitor and document episodes

2. Avoid antibiotic overuse:

   • Do not prescribe antibiotics for viral tonsillitis
   • Antibiotics provide no benefit against viral infections and contribute to resistance 2

3. Beware of incomplete documentation:

   • Without proper documentation of frequency and severity, appropriate management decisions cannot be made 1

4. Consider beta-lactamase producing bacteria:

   • Treatment failure with penicillin may be due to beta-lactamase producing bacteria in tonsillar tissue
   • In recurrent cases, amoxicillin/clavulanate has shown superior results compared to penicillin alone 6

5. Recognize chronic carriers:

   • Some patients with recurrent symptoms may be chronic GAS carriers experiencing viral infections
   • These patients require different management approaches 2