What is the treatment for phlegmonous tonsillitis?

Treatment for Phlegmonous Tonsillitis

For phlegmonous tonsillitis, penicillin V for 10 days is the first-line treatment after confirming Group A Streptococcal (GAS) infection through rapid antigen detection testing or throat culture. 1, 2

Diagnosis

• Phlegmonous tonsillitis is characterized by sudden onset of sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2
• Testing with rapid antigen detection test (RADT) and/or throat culture for Group A Streptococcus (GAS) is recommended before initiating antibiotics 1

First-Line Treatment Options

• Penicillin V oral for 10 days is the first-line treatment for confirmed bacterial tonsillitis 3, 2
  • Children: 250 mg twice or three times daily
  • Adolescents and adults: 250 mg four times daily or 500 mg twice daily 3
• Amoxicillin for 10 days is an acceptable alternative first-line treatment 1, 2
  • 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) 3
• Benzathine penicillin G intramuscular is another option 3
  • <27 kg: 600,000 U
  • ≥27 kg: 1,200,000 U

Treatment for Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: First-generation cephalosporins for 10 days 2
  • Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) 3
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g) 3
• For anaphylactic penicillin allergy: 2
  • Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 3
  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 3
  • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 3

Important Considerations

• The standard 10-day course of antibiotics is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1, 2
• Short courses (5 days) of penicillin are less effective for GAS eradication and should be avoided 2, 4
• Initiating antibiotics without confirming GAS infection through testing is not recommended 1, 2

Management of Recurrent Tonsillitis

• For documented recurrent GAS tonsillitis within 2 weeks of completing standard therapy, consider: 2
  • Clindamycin: 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days
  • Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses (maximum 2000 mg amoxicillin/day) for 10 days
  • Penicillin with rifampin: Penicillin V for 10 days plus rifampin for the last 4 days of treatment

Surgical Management

• Tonsillectomy is not recommended solely to reduce the frequency of GAS pharyngitis 3, 2
• Consider tonsillectomy only for patients with recurrent, documented episodes of bacterial tonsillitis that meet specific frequency criteria and don't respond to appropriate antibiotic therapy 1, 2
• For peritonsillar abscess (a complication of tonsillitis), surgical drainage by either hot tonsillectomy or incision under local anesthesia with appropriate antibiotic therapy is required 5

Supportive Care

• NSAIDs (e.g., ibuprofen) for pain and fever 2
• Warm salt water gargles for symptomatic relief 2

Common Pitfalls to Avoid

• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 2
• Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 1, 2
• Performing tonsillectomy solely to reduce the frequency of GAS pharyngitis without meeting established frequency criteria 1