What is the recommended treatment for exudative tonsillitis?

Treatment of Exudative Tonsillitis

Penicillin V 250 mg four times daily (or 500 mg twice daily) for 10 days is the first-line treatment for confirmed bacterial exudative tonsillitis caused by group A streptococcus, but antibiotics should only be prescribed after microbiologic confirmation with rapid antigen detection testing (RADT) or throat culture, as the majority of exudative tonsillitis cases in children are viral and do not require antibiotics. 1, 2, 3

Diagnostic Approach: Test Before Treating

The presence of tonsillar exudate does not confirm bacterial infection—this is a critical pitfall. 4, 5

• Obtain RADT and/or throat culture before prescribing antibiotics to confirm group A streptococcus (GAS), as viral causes (especially Epstein-Barr virus, cytomegalovirus, adenovirus, and enterovirus) account for 70-95% of exudative tonsillitis cases. 1, 2, 4, 5

• Use the McIsaac scoring system to guide testing decisions: assign +1 point each for temperature ≥38°C, absence of cough, tender anterior cervical adenopathy, tonsillar swelling/exudate, and age <15 years; subtract 1 point for age ≥45 years. 1

  • Score 0-1: Neither antibiotics nor culture required 1
  • Score 2-3: Obtain culture, base antibiotic decision on result 1
  • Score 4+: Initiate antibiotics immediately or obtain culture 1

• Do not rely on clinical appearance alone—studies show GAS accounts for only 1-5% of pediatric exudative tonsillitis cases, while viruses cause nearly half. 4, 5

First-Line Antibiotic Treatment (Confirmed GAS Only)

Once GAS is confirmed, select from these evidence-based regimens:

For Patients Without Penicillin Allergy:

• Penicillin V oral: Children 250 mg twice or three times daily; adolescents/adults 250 mg four times daily or 500 mg twice daily for 10 days 1, 2, 3

• Amoxicillin oral: 50 mg/kg once daily (max 1000 mg) or 25 mg/kg twice daily (max 500 mg per dose) for 10 days 1, 2, 3

• Benzathine penicillin G intramuscular: <27 kg: 600,000 units; ≥27 kg: 1,200,000 units as a single dose 1

For Penicillin-Allergic Patients (Non-Anaphylactic):

• Cephalexin oral: 20 mg/kg/dose twice daily (max 500 mg/dose) for 10 days 1, 2

• Cefadroxil oral: 30 mg/kg once daily (max 1 g) for 10 days 1, 2

For Penicillin-Allergic Patients (Anaphylactic):

• Clindamycin oral: 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days 1, 2

• Azithromycin oral: 12 mg/kg once daily (max 500 mg) for 5 days (note: resistance varies geographically) 1, 2

• Clarithromycin oral: 7.5 mg/kg/dose twice daily (max 250 mg/dose) for 10 days 1, 2

Critical Treatment Duration Considerations

The full 10-day course is mandatory for penicillin and most antibiotics to maximize bacterial eradication and prevent acute rheumatic fever. 1, 2, 3, 6

• Shorter courses (5 days) of standard-dose penicillin are inadequate and increase treatment failure rates from 2-10% to approximately 30%. 1, 2, 7

• The only exception is azithromycin (5 days), but macrolide resistance is a concern. 1

Viral Exudative Tonsillitis: Supportive Care Only

For viral causes (confirmed by negative GAS testing or clinical suspicion of EBV/CMV):

• Provide symptomatic relief with NSAIDs (ibuprofen) or acetaminophen for pain and fever control 2, 6

• Ensure adequate hydration and rest 6

• Do not prescribe antibiotics—they provide no benefit and contribute to resistance 2, 3, 6

• Elevated transaminase levels may suggest viral etiology (especially EBV or CMV) and help avoid unnecessary antibiotics 4

Management of Recurrent Exudative Tonsillitis

If symptoms return shortly after completing antibiotics:

• Consider clindamycin 20-30 mg/kg/day in 3 doses (max 300 mg/dose) for 10 days as first-line for documented recurrent GAS 2

• Alternative: Amoxicillin-clavulanate 40 mg amoxicillin/kg/day in 3 doses (max 2000 mg/day) for 10 days 2

• Evaluate for chronic GAS carriage with intercurrent viral infections rather than true recurrent bacterial infection—up to 20% of school-age children are asymptomatic carriers. 2

Tonsillectomy Considerations:

Watchful waiting is strongly recommended unless specific frequency criteria are met. 1, 3

• Do not perform tonsillectomy if episodes are <7 in the past year, <5 per year for 2 years, or <3 per year for 3 years 1, 3

• May consider tonsillectomy only when meeting Paradise criteria: ≥7 documented episodes in past year, ≥5 per year for 2 years, or ≥3 per year for 3 years, with each episode documented showing temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 1, 2, 3, 6

• Tonsillectomy is not recommended solely to reduce GAS pharyngitis frequency 1, 2, 3

Common Pitfalls to Avoid

• Never prescribe antibiotics based on exudate alone—the majority of exudative tonsillitis is viral, especially in children. 2, 3, 4, 5

• Never use broad-spectrum antibiotics when narrow-spectrum penicillin is effective for confirmed GAS 2, 3

• Never prescribe antibiotic courses shorter than 10 days for GAS (except azithromycin 5 days), as this increases treatment failure risk 1, 2, 3

• Do not perform routine follow-up throat cultures in asymptomatic patients who completed appropriate therapy 2

• Avoid using ASO titers to guide acute treatment decisions—they reflect past immunologic response, not current infection status 2