How to manage a patient with tonsillitis and purulent discharge?

Management of Tonsillitis with Purulent Exudate

For patients presenting with swollen tonsils and purulent discharge, you must first confirm Group A Streptococcus (GAS) infection through rapid antigen detection testing (RADT) or throat culture before initiating antibiotics, then treat confirmed bacterial cases with penicillin V or amoxicillin for a full 10-day course. 1, 2

Diagnostic Approach

Test before treating—never prescribe antibiotics empirically for purulent tonsillitis. 2, 3

• Perform RADT and/or throat culture for GAS before any antibiotic therapy to prevent unnecessary antibiotic use, as 70-95% of tonsillitis cases are viral despite the presence of exudate 2, 4, 5
• Look for bacterial indicators: sudden onset sore throat, fever >39°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 3
• Viral tonsillitis typically presents without high fever and lacks significant cervical lymphadenopathy, though exudate can occasionally be present 2, 3
• Do not rely on clinical appearance alone—purulent exudate can occur with both viral (especially EBV) and bacterial infections 4, 5

Treatment Algorithm for Confirmed GAS Tonsillitis

First-Line Antibiotic Therapy (No Penicillin Allergy)

Prescribe penicillin V or amoxicillin for exactly 10 days—shorter courses increase treatment failure and do not prevent rheumatic fever. 1, 2

• Penicillin V: Children 250 mg twice or three times daily; adolescents/adults 250 mg four times daily or 500 mg twice daily for 10 days 1
• Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 6
• Benzathine penicillin G (intramuscular): Single dose of 600,000 units if <27 kg or 1,200,000 units if ≥27 kg—use when compliance is a concern 1

Alternative Therapy for Penicillin Allergy

Distinguish between non-anaphylactic and anaphylactic penicillin allergy to guide antibiotic selection. 1, 2

• Non-anaphylactic allergy: Use first-generation cephalosporins (cephalexin 20 mg/kg/dose twice daily, maximum 500 mg per dose, for 10 days) 1, 2
• Anaphylactic allergy: Use clindamycin (7 mg/kg three times daily, maximum 300 mg per dose, for 10 days), azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days), or clarithromycin (7.5 mg/kg twice daily, maximum 250 mg per dose, for 10 days) 1, 2
• Warning: Macrolide resistance varies geographically and temporally—consider local resistance patterns 1, 7

Treatment for Viral Tonsillitis

If GAS testing is negative, provide supportive care only—no antibiotics. 2, 8, 4

• Prescribe ibuprofen or acetaminophen for pain control (avoid aspirin in children) 1, 8
• Emphasize adequate hydration and rest 8, 4
• Educate patients that viral tonsillitis with exudate (including EBV mononucleosis) resolves without antibiotics 8, 4

Management of Treatment Failures

If symptoms persist beyond 48-72 hours despite appropriate antibiotic therapy, consider medication non-compliance, beta-lactamase producing bacteria, or chronic GAS carriage with intercurrent viral infection. 3, 9

• Switch to amoxicillin-clavulanate, clindamycin, or second/third-generation cephalosporins for documented treatment failures 1, 3, 9
• Beta-lactamase producing bacteria (BLPB) are recovered from >75% of tonsils in recurrent infection cases and can "shield" GAS from penicillin 9
• Do not perform routine follow-up throat cultures in asymptomatic patients who completed appropriate therapy 1, 2, 3

Surgical Consideration: Tonsillectomy

Reserve tonsillectomy for patients meeting Paradise criteria with proper documentation—do not perform surgery solely to reduce infection frequency without meeting these thresholds. 1, 2

• Paradise criteria: ≥7 documented episodes in the past year, OR ≥5 episodes per year for 2 consecutive years, OR ≥3 episodes per year for 3 consecutive years 2, 8, 5
• Each episode must be documented with temperature, cervical adenopathy, tonsillar exudate, or positive GAS test 2, 8
• Watchful waiting is strongly recommended if frequency thresholds are not met 1, 2, 5

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing—this drives unnecessary antibiotic use and resistance 1, 2, 3
• Never prescribe antibiotic courses shorter than 10 days for confirmed GAS—this maximizes treatment failure and does not prevent rheumatic fever or glomerulonephritis 1, 2, 3
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective—amoxicillin-clavulanate should be reserved for treatment failures, not first-line therapy 2, 9
• Never assume purulent exudate equals bacterial infection—viral causes (especially EBV) commonly produce exudative tonsillitis 4, 5
• Never routinely prescribe perioperative antibiotics for tonsillectomy—evidence shows no benefit 1, 8

Adjunctive Symptomatic Management

Provide analgesics and antipyretics for moderate to severe symptoms regardless of etiology. 1

• Use acetaminophen or NSAIDs for pain and fever control 1
• Avoid aspirin in children due to Reye syndrome risk 1
• Corticosteroids are not recommended for routine GAS pharyngitis treatment 1
• If tonsillectomy is performed, administer single intraoperative dose of IV dexamethasone (0.5 mg/kg) to reduce postoperative nausea, vomiting, and pain 1, 8