What is the next step in treating recurrent tonsillitis that has not responded to Zpack (azithromycin) and Augmentin (amoxicillin-clavulanate)?

Treatment of Recurrent Tonsillitis After Failed Azithromycin and Augmentin

For recurrent tonsillitis that has failed both azithromycin and amoxicillin-clavulanate, the next step is to treat with clindamycin 20-30 mg/kg/day divided into 3 doses for 10 days (or 600 mg/day in adults divided into 2-4 doses), as this is the first-line agent recommended by the Infectious Diseases Society of America for recurrent episodes. 1

Immediate Management Approach

First: Confirm True Recurrent Infection vs. Carrier State

Before escalating therapy, you must distinguish between:

• True recurrent Group A Streptococcal (GAS) pharyngitis: Multiple bona fide infections requiring aggressive treatment 1
• Chronic GAS carrier with viral infections: Patient colonized with GAS (up to 20% of school-age children) who experiences intercurrent viral pharyngitis that tests positive for GAS but doesn't represent true bacterial infection 1

Key differentiating features:

• Carriers lack rising anti-streptococcal antibody titers and have no active immunologic response 1
• Carriers are at very low risk for complications and unlikely to spread infection to contacts 1
• If the patient is a carrier, antimicrobial therapy is not indicated 1

Second: Use Appropriate Antimicrobial Regimen

Since the patient has already failed Augmentin (which you already tried), the IDSA guidelines provide these options for recurrent/treatment-failure cases 1:

Recommended regimens in order of preference:

1. Clindamycin (first choice):

   • Children: 20-30 mg/kg/day divided into 3 doses for 10 days (max 300 mg/dose) 1
   • Adults: 600 mg/day divided into 2-4 doses for 10 days 1
   • Evidence rating: Strong, high quality 1
   • Important caveat: Clindamycin carries risk of Clostridioides difficile-associated diarrhea (CDAD), which can range from mild diarrhea to fatal colitis 2

2. Benzathine penicillin G IM with rifampin:

   • Single IM dose of benzathine penicillin G plus rifampin 20 mg/kg/day orally in 2 divided doses for the last 4 days (max 600 mg/day) 1
   • Particularly useful when compliance is questionable 1
   • Rifampin is relatively contraindicated in pregnancy 1

Note on macrolides and cephalosporins: The IDSA explicitly states these are NOT included in recommendations for recurrent tonsillitis because there are insufficient data to support their efficacy in this specific circumstance 1. This explains why azithromycin (a macrolide) failed—research shows only 40% efficacy in preventing recurrence 3.

When to Consider Tonsillectomy

Paradise Criteria for Surgical Referral

Tonsillectomy should be considered if the patient meets Paradise criteria 1, 4:

• ≥7 episodes in the past year, OR
• ≥5 episodes per year for 2 consecutive years, OR
• ≥3 episodes per year for 3 consecutive years 4

Each episode must be documented with:

• Temperature >38.3°C (101°F), OR
• Cervical adenopathy, OR
• Tonsillar exudate, OR
• Positive test for Group A beta-hemolytic streptococcus 4
• Episodes must have been treated with antibiotics in conventional dosage 4

Modifying Factors That Lower Threshold for Surgery

Consider tonsillectomy even without meeting full Paradise criteria if 4, 5:

• Multiple antibiotic allergies/intolerances 4
• PFAPA syndrome (Periodic Fever, Aphthous stomatitis, Pharyngitis, Adenitis) 4
• History of >1 peritonsillar abscess 4, 5

Important Caveat About Tonsillectomy

The 2012 IDSA guidelines state they do NOT recommend tonsillectomy solely to reduce the frequency of GAS pharyngitis (strong recommendation, high-quality evidence) 1. The 2011 AAO-HNS guidelines are more permissive, stating tonsillectomy is "an option" for children meeting Paradise criteria 1. However, both acknowledge that:

• Tonsillectomy may decrease recurrences but only for a limited time 1
• Many cases improve spontaneously—untreated children averaged only 1.17 episodes in year 1.03 in year 2, and 0.45 in year 3 4
• Watchful waiting is strongly recommended for patients not meeting Paradise criteria 4

Clinical Pitfalls to Avoid

1. Don't routinely test or treat asymptomatic contacts: Family members don't need throat cultures or RADT unless symptomatic 1

2. Don't use long-term antibiotic prophylaxis: Continuous prophylaxis is not recommended except for patients with history of rheumatic fever 1

3. Don't perform routine post-treatment cultures: Only retest if symptoms recur 1

4. Don't assume all positive tests mean active infection: Consider carrier state, especially if episodes are frequent and close together 1

5. Monitor for clindamycin complications: If using clindamycin, warn patients about CDAD risk and consider monitoring renal function, especially in patients with pre-existing renal dysfunction 2