What is the recommended treatment for acute bacterial tonsillitis in children?

Treatment of Acute Bacterial Tonsillitis in Children

For acute bacterial tonsillitis caused by Group A β-hemolytic Streptococcus (GABHS) in children, penicillin V or amoxicillin for 10 days remains the first-line treatment, though high-dose penicillin four times daily for 5 days or oral cephalosporins for 5 days are acceptable alternatives. 1

First-Line Antibiotic Selection

Penicillin-Based Therapy (Preferred)

• Amoxicillin is the recommended first-line agent for most children with bacterial tonsillitis 2, 3

  • Dosing: 40-50 mg/kg/day divided twice or three times daily 4
  • Duration: Standard 10-day course 1
  • Amoxicillin 45 mg/kg/day given twice daily is as effective as 40 mg/kg/day given three times daily, improving compliance 4

• Penicillin V remains an acceptable alternative 1

  • Standard dosing: 50,000 IU/kg (30 mg/kg) three times daily for 10 days 5
  • High-dose alternative: Four times daily dosing for 5 days achieves non-inferior clinical cure (89.6% vs 93.3% for 10-day standard dose) 1

Cephalosporin Alternatives

• Cefuroxime axetil 20 mg/kg/day (max 500 mg) twice daily for 5 days is as effective as 10-day penicillin V 5

  • Bacteriological eradication: 90.52% (ages 1-5) and 89.53% (ages 6-17) versus 84.13% and 84.20% with penicillin V 5
  • Clinical success: 98.30% versus 93.25% with penicillin V 5

• Other oral cephalosporins (cefpodoxime, cefdinir) are options for penicillin-allergic patients with non-Type I hypersensitivity reactions 1

Macrolide Therapy

Azithromycin

• Dosing for pharyngitis/tonsillitis: 12 mg/kg once daily for 5 days 6
• Alternative: 10 mg/kg as single dose on Day 1, then 5 mg/kg daily on Days 2-5 6
• Clinical efficacy comparable to 10-day penicillin V (98% cure/improvement vs 100%) 7
• Bacterial eradication: 95% at day 11, similar to penicillin V 7

Important caveat: Macrolides should NOT be routinely recommended due to increasing GABHS resistance, despite their convenience 1. Reserve for documented penicillin allergy with Type I hypersensitivity reaction 1.

Duration of Therapy Considerations

The evidence shows nuanced duration recommendations:

• Standard 10-day penicillin course is derived from streptococcal pharyngotonsillitis treatment protocols and remains the benchmark 1
• 5-day short courses are acceptable when using:
  • High-dose penicillin four times daily (total dose 16g vs 30g for standard 10-day course) 1
  • Oral cephalosporins like cefuroxime axetil 5
• Standard-dose penicillin for 5 days is LESS effective (OR 0.43; 95% CI 0.23-0.82) and should be avoided 1

Penicillin Allergy Management

Non-Type I Hypersensitivity

• Second- or third-generation cephalosporins are safe; risk of serious allergic reaction is negligible 1
• Options: cefdinir, cefpodoxime, cefuroxime 1

Type I Hypersensitivity (Immediate Reaction)

• Macrolides: azithromycin, clarithromycin, or erythromycin 1
• Warning: These have limited effectiveness with bacterial failure rates of 20-25% 1
• Clindamycin is appropriate if S. pneumoniae is identified 1

Treatment Failure Protocol

If no improvement within 72 hours 1:

1. Reassess diagnosis to confirm bacterial tonsillitis and exclude other causes 1
2. Consider treatment failure causes:
   • Non-compliance with medication
   • β-lactamase producing organisms
   • Resistant pathogens
3. Switch antibiotic therapy:
   • If initially on amoxicillin → switch to amoxicillin-clavulanate or cephalosporin 1
   • If initially on cephalosporin → consider culture and sensitivity testing 1

Age-Specific Considerations

Younger children (1-5 years) have significantly higher recurrence rates regardless of treatment regimen 5. This population requires:

• Closer follow-up monitoring
• Emphasis on medication compliance
• Consideration of twice-daily dosing regimens to improve adherence 4

Critical Pitfalls to Avoid

1. Do not use standard-dose penicillin for only 5 days – this is inferior to 10-day courses 1
2. Do not routinely prescribe macrolides – reserve for true penicillin allergy due to resistance concerns 1
3. Do not assume all "penicillin allergies" are Type I – most patients can safely receive cephalosporins 1
4. Do not ignore treatment failure at 72 hours – this requires reassessment and antibiotic change 1

Rare Complications Context

While these studies cannot adequately address suppurative complications (peritonsillar abscess) or non-suppurative complications (rheumatic fever, glomerulonephritis) due to their rarity, only one case of poststreptococcal glomerulonephritis was observed across large pediatric studies, occurring in the penicillin V group 5. The low incidence of rheumatic fever in developed countries supports the use of shorter cephalosporin courses 5.