What is the treatment for an 8-year-old with streptococcal (strep) pharyngitis after a tonsillectomy?

Treatment of Streptococcal Pharyngitis in an 8-Year-Old Post-Tonsillectomy

For an 8-year-old child with streptococcal pharyngitis after tonsillectomy, penicillin V or amoxicillin for 10 days is the recommended first-line treatment, with alternative antibiotics for those with penicillin allergies. 1

First-Line Treatment Options

• Penicillin V oral: 250 mg two or three times daily for 10 days 1
• Amoxicillin oral: 50 mg/kg once daily (maximum 1,000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1

These medications remain the treatment of choice due to their proven efficacy, safety, narrow spectrum of activity, and low cost 1.

Alternative Treatment for Penicillin-Allergic Patients

For patients with penicillin allergy, the following alternatives are recommended:

• Non-anaphylactic penicillin allergy:

  • Cephalexin (Keflex): 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1

• Anaphylactic penicillin allergy:

  • Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1
  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 2
  • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1

Special Considerations Post-Tonsillectomy

Despite tonsillectomy, streptococcal pharyngitis can still occur as the infection can affect the remaining pharyngeal tissues. The treatment approach remains the same as for patients with tonsils 3, 4.

• Complete the full course of antibiotics even if symptoms improve 3
• Consider adjunctive therapy with acetaminophen or NSAIDs for pain and fever control 1
• Avoid aspirin in children due to risk of Reye syndrome 1
• Corticosteroids are not recommended for routine treatment of streptococcal pharyngitis 1, 5

Monitoring and Follow-Up

• Follow-up post-treatment testing is not routinely recommended for asymptomatic patients who have completed appropriate antibiotic therapy 1
• If symptoms worsen after antibiotic initiation or persist for 5 days after starting treatment, the patient should be reevaluated 6

Important Considerations

• Macrolide resistance (azithromycin, clarithromycin) varies geographically and can be significant in some areas of the United States 1, 6
• Penicillin remains the drug of choice for preventing rheumatic fever, a potential complication of untreated streptococcal pharyngitis 2
• For recurrent streptococcal infections, alternative regimens such as clindamycin, amoxicillin-clavulanate, or penicillin with rifampin may be considered 4

Management of Recurrent Infections

If this represents a recurrent infection pattern despite tonsillectomy:

• Consider testing for chronic streptococcal carriage with repeated viral infections rather than recurrent streptococcal infections 1
• For confirmed recurrent streptococcal infections, consider alternative regimens:
  • Clindamycin: 20-30 mg/kg/day in three doses (maximum 300 mg per dose) for 10 days 1
  • Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in three doses (maximum 2,000 mg amoxicillin per day) for 10 days 1

The unexpected occurrence of streptococcal pharyngitis after tonsillectomy warrants careful documentation and monitoring for potential complications or underlying issues 3.