What is the treatment for streptococcal (strep) infection in a patient without tonsils?

Treatment of Streptocococcal Pharyngitis in Patients Without Tonsils

Treat streptococcal pharyngitis in patients without tonsils with the same antibiotic regimens used for patients with intact tonsils: penicillin or amoxicillin for 10 days as first-line therapy. 1

The absence of tonsils does not change the fundamental approach to treating Group A streptococcal pharyngitis. The infection involves the oropharynx and nasopharynx, not exclusively the tonsils, and the treatment goals remain identical: preventing acute rheumatic fever, preventing suppurative complications, reducing symptoms, and decreasing transmission. 1

First-Line Treatment Options

For patients without penicillin allergy:

• Penicillin V (oral) is the preferred first-line agent due to its narrow spectrum, proven efficacy, safety, and low cost 1:

  • Children: 250 mg two or three times daily for 10 days 1
  • Adolescents and adults: 250 mg four times daily OR 500 mg twice daily for 10 days 1

• Amoxicillin (oral) is equally effective and often preferred in children due to better taste acceptance 1:

  • 50 mg/kg once daily (maximum 1,000 mg) for 10 days 1
  • Alternative: 25 mg/kg twice daily (maximum 500 mg) for 10 days 1

• Penicillin G benzathine (intramuscular) should be used when compliance with oral therapy is questionable 1:

  • <60 lb (27 kg): 600,000 units as a single dose 1
  • ≥60 lb: 1,200,000 units as a single dose 1

Treatment for Penicillin-Allergic Patients

For non-immediate (non-anaphylactic) penicillin allergy:

• First-generation cephalosporins are appropriate 1, 2:
  • Cephalexin: 20 mg/kg per dose twice daily (maximum 500 mg per dose) for 10 days 1
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1

For immediate-type hypersensitivity to penicillin:

• Clindamycin (oral) is the preferred alternative 1:

  • 7 mg/kg per dose three times daily (maximum 300 mg per dose) for 10 days 1

• Azithromycin may be used but has significant geographic resistance 3, 2:

  • 12 mg/kg once daily (maximum 500 mg) for 5 days 1
  • Resistance rates vary significantly; susceptibility testing should be performed when possible 3

• Clarithromycin also has variable resistance patterns 1:

  • 7.5 mg/kg per dose twice daily (maximum 250 mg per dose) for 10 days 1
  • Not recommended in areas with high clarithromycin resistance 4

Critical Treatment Duration Considerations

The full 10-day course is essential for penicillin and most oral antibiotics to achieve maximal pharyngeal eradication of streptococci. 1 Shorter courses have not been adequately validated and cannot be recommended, despite some newer agents showing promise in limited studies. 1

The only exception is azithromycin, which requires only 5 days due to its prolonged tissue half-life. 1 However, given increasing resistance patterns, azithromycin should be reserved for patients with true penicillin allergy. 2

Important Clinical Pitfalls

Avoid these common errors:

• Do not use once-daily penicillin V dosing, as it is associated with cure rates 12 percentage points lower than more frequent dosing 5
• Do not rely on oral antibiotics in patients with severe illness, nausea, vomiting, or intestinal hypermotility 6
• Do not use azithromycin or clarithromycin as first-line therapy when penicillin can be used, as this contributes to antimicrobial resistance 7, 4
• Do not prescribe corticosteroids as adjunctive therapy 1, 2
• Do not use aspirin in children due to Reye syndrome risk 1

Management of Treatment Failures

If a patient experiences recurrent pharyngitis shortly after completing therapy, consider 1:

• Retreatment with the same regimen if compliance was adequate 1
• Intramuscular benzathine penicillin G if compliance is questionable 1
• Clindamycin for chronic carriers or multiple treatment failures 1:
  • 20-30 mg/kg per day in three doses (maximum 300 mg per dose) for 10 days 1

Adjunctive Symptomatic Treatment

For moderate to severe symptoms or high fever:

• Acetaminophen or NSAIDs may be used for symptom relief 1
• Avoid aspirin in children 1
• Corticosteroids are not recommended 1, 8

The key principle is that tonsillectomy status does not alter the microbiology, pathophysiology, or treatment approach to streptococcal pharyngitis. The same evidence-based antibiotic regimens apply regardless of whether tonsils are present. 1