How do you treat prolonged tonsillitis or pharyngitis?

Treatment of Prolonged Tonsillitis

For prolonged tonsillitis, first-line treatment should be penicillin V or amoxicillin for 10 days, with alternative regimens such as clindamycin, amoxicillin-clavulanate, or combination therapy for recurrent cases that don't respond to initial treatment. 1, 2

Diagnostic Approach

• Differentiate between viral (70-95% of cases) and bacterial tonsillitis (5-15% in adults, 15-30% in children aged 5-15) before initiating treatment 3
• Bacterial tonsillitis is characterized by sudden onset of sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1
• Confirm bacterial etiology through rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) before prescribing antibiotics 1, 4

First-Line Treatment for Bacterial Tonsillitis

• Penicillin V oral for 10 days is the recommended first-line treatment for confirmed GAS tonsillitis 1, 4
• Amoxicillin is an equivalent alternative to penicillin, with better taste for children and once-daily dosing option (50 mg/kg once daily for 10 days) 1, 2
• The standard 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1, 2

Treatment for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: First-generation cephalosporins (cefalexin, cefadroxil) for 10 days 1
• For anaphylactic penicillin allergy: Clindamycin (7 mg/kg/dose three times daily for 10 days), azithromycin (12 mg/kg once daily for 5 days), or clarithromycin (7.5 mg/kg/dose twice daily for 10 days) 1, 5

Management of Recurrent Tonsillitis

• For recurrent documented GAS tonsillitis after completing standard therapy, consider alternative regimens: 4, 1
  • Clindamycin: 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days 4, 1
  • Amoxicillin-clavulanate: 40 mg/kg/day in 3 doses for 10 days 4, 1, 6
  • Penicillin with rifampin: Penicillin V for 10 days plus rifampin for the last 4 days of treatment 1

Criteria for Watchful Waiting vs. Surgical Intervention

• Watchful waiting is strongly recommended 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 4
• Tonsillectomy may be considered for recurrent throat infection with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years with proper documentation 4, 7
• Surgical removal should only be considered for patients whose symptomatic episodes do not diminish in frequency over time and for whom no alternative explanation is evident 4

Supportive Care

• Symptomatic relief with NSAIDs (e.g., ibuprofen) for pain and fever 1, 7
• Warm salt water gargles for patients old enough to do so 1
• Adequate hydration and rest 8

Important Considerations and Pitfalls

• Short courses (5 days) of antibiotics are less effective for GAS eradication and should be avoided 1, 2
• Follow-up throat cultures are not recommended for asymptomatic patients who have completed appropriate antibiotic therapy 4, 1
• Avoid initiating antibiotic therapy without confirming GAS infection through testing 1, 9
• Consider the possibility of chronic GAS carriage with intercurrent viral infections in patients with frequent recurrences 1, 4
• Use narrow-spectrum antibiotics when effective rather than broad-spectrum options 1, 9