What is the next step in management for a patient with persistent tonsillitis, despite antibiotic treatment, presenting with fever and leukocytosis (White Blood Cell count of 16)?

From the Guidelines

For a patient with persistent tonsillitis, despite antibiotic treatment, presenting with fever and leukocytosis (White Blood Cell count of 16), I strongly recommend immediate referral to an otolaryngologist (ENT specialist) for evaluation and possible tonsillectomy, as this presentation suggests a severe case that may require specialist intervention. The patient's condition, with fever and elevated white blood cell count, indicates a potential complication such as a peritonsillar abscess or severe refractory tonsillitis, which aligns with the recommendations for tonsillectomy in cases of recurrent throat infection with modifying factors, as stated in the clinical practice guideline: tonsillectomy in children (update) 1.

While awaiting the ENT appointment, the patient should be started on a broader-spectrum antibiotic such as clindamycin 300-450mg orally four times daily or amoxicillin-clavulanate 875/125mg twice daily, as these are commonly used for treating severe or refractory tonsillitis. The patient should also maintain adequate hydration, use salt water gargles (1/2 teaspoon salt in 8oz warm water) 4-6 times daily, and take acetaminophen or ibuprofen for pain and fever control.

Key considerations in managing this patient include:

• The presence of fever and leukocytosis, which are indicative of a significant infection or inflammation.
• The failure of initial antibiotic therapy, which suggests either antibiotic resistance or a complication such as an abscess.
• The potential for airway compromise, which would necessitate emergency care if the patient develops difficulty swallowing, breathing difficulties, drooling, or severe pain.

The clinical practice guidelines for tonsillectomy in children, as outlined in the studies 1, emphasize the importance of documentation of the frequency and clinical features of throat infection episodes to ensure clinical benefits consistent with those achieved in randomized controlled trials. However, in the context of a patient with persistent symptoms despite antibiotic treatment and signs of severe infection, the priority should be immediate referral for specialist evaluation rather than further observation or documentation.

From the Research

Management of Persistent Tonsillitis

• The provided studies do not directly address the management of persistent tonsillitis despite antibiotic treatment, presenting with fever and leukocytosis (White Blood Cell count of 16) 2, 3, 4, 5, 6.
• However, the studies suggest that alternative antibiotic therapies, such as daptomycin and linezolid, can be effective in treating persistent infections caused by methicillin-resistant Staphylococcus aureus (MRSA) 2, 4, 5.
• The use of salvage therapy with daptomycin, linezolid, and meropenem has been reported to be effective in clearing persistent MRSA bacteremia 2.
• Oxazolidinones, such as tedizolid and linezolid, have been considered for managing toxic shock caused by clindamycin-resistant Group A Streptococcus (GAS; Streptococcus pyogenes) 6.
• It is essential to note that the management of chronic illnesses, including the continuation of therapy during hospitalization, is crucial, and factors such as pain, anxiety, and poor sleep hygiene can impact the patient's condition 3.

Antibiotic Therapy

• The studies highlight the importance of selecting appropriate antibiotic therapy based on the patient's specific condition and the causative organism 2, 4, 5, 6.
• The use of combination therapy, such as daptomycin and linezolid, may be effective in treating persistent infections 2, 4, 5.
• The selection of antibiotic therapy should be guided by the results of blood cultures and sensitivity testing 2, 4, 5, 6.

Patient Care

• Hospitalized patients require continued management of their chronic conditions, including the management of blood glucose levels, blood pressure, and pain 3.
• The identification and management of alcohol withdrawal syndrome are crucial in hospitalized patients 3.
• Venous thromboprophylaxis is recommended for all but low-risk patients to prevent venous thromboembolic disease 3.