What antibiotic can be safely prescribed to a breastfeeding mother with tonsillitis?

Antibiotic Treatment for Tonsillitis in Breastfeeding Mothers

Amoxicillin or amoxicillin/clavulanic acid (Augmentin) are the first-line antibiotics for tonsillitis in breastfeeding mothers, as they are explicitly classified as "compatible" with breastfeeding and have the strongest safety evidence. 1, 2, 3

First-Line Antibiotic Choices

Amoxicillin (Preferred)

• Amoxicillin is classified as "compatible" with breastfeeding by the European Respiratory Society/Thoracic Society of Australia and New Zealand (ERS/TSANZ) guidelines and the American Academy of Dermatology, representing the highest safety designation for antibiotics during lactation. 1, 2
• Penicillins are present in breast milk at low concentrations and have extensive safety data supporting their use during breastfeeding. 2, 4
• Standard dosing is 250-500 mg three times daily for bacterial tonsillitis. 2

Amoxicillin/Clavulanic Acid (Co-amoxiclav/Augmentin)

• This combination is classified as FDA Category B and "compatible" with breastfeeding, recommended by both the American Academy of Dermatology and ERS/TSANZ guidelines. 2, 3
• Use the lowest effective dose for the shortest necessary duration to minimize infant exposure while maintaining therapeutic efficacy. 3
• Monitor breastfed infants for mild gastrointestinal effects (diarrhea, changes in stool pattern) due to potential alteration of intestinal flora, though serious adverse events are rare. 2, 3

Alternative Options for Penicillin-Allergic Patients

Cephalosporins (First Alternative)

• Cephalosporins including cephalexin and ceftriaxone are classified as "compatible" with breastfeeding by ERS/TSANZ guidelines. 1, 2
• Most studies demonstrate that cephalosporins are safe during lactation with low presence in breast milk. 1, 2
• These are preferred over macrolides for penicillin-allergic patients when cross-reactivity is not a concern. 2

Azithromycin (Second Alternative)

• Azithromycin is classified as "probably safe" during breastfeeding, but should ideally be avoided during the first 13 days postpartum. 1, 2
• There is a very low risk of hypertrophic pyloric stenosis in infants exposed to macrolides during the first 13 days of breastfeeding, but this risk does not persist after 2 weeks. 1, 2
• After the first 2 weeks postpartum, azithromycin is an acceptable alternative for penicillin-allergic patients. 2

Erythromycin (Third Alternative)

• Erythromycin is suggested as safe for penicillin-allergic patients by the American Academy of Dermatology. 1, 2
• The same precaution regarding pyloric stenosis applies during the first 13 days postpartum. 1
• Erythromycin estolate should be avoided due to potential maternal hepatotoxicity. 1

Antibiotics Requiring Caution or Avoidance

Clindamycin

• Use oral clindamycin with caution as it may increase the risk of GI side effects in the infant, including diarrhea, candidiasis, or rarely antibiotic-associated colitis. 2
• Topical clindamycin has significantly lower systemic absorption and is safer if specifically indicated. 2

Doxycycline

• Limit doxycycline use to 3 weeks maximum without repeating courses, and only if no suitable alternative is available. 1, 2
• Tetracyclines are associated with tooth discoloration and transient suppression of bone growth in infants. 1

Fluoroquinolones

• Fluoroquinolones should not be used as first-line treatment during breastfeeding. 2
• If absolutely necessary, ciprofloxacin is the preferred fluoroquinolone due to lower concentration in breast milk. 2

Essential Monitoring Considerations

• All breastfed infants whose mothers are taking antibiotics should be monitored for gastrointestinal effects (diarrhea, gastroenteritis) due to alteration of intestinal flora. 1, 2, 3
• Antibiotics in breast milk could potentially cause falsely negative cultures if the breastfed infant develops fever requiring evaluation. 2, 5
• Breastfeeding should not be interrupted when appropriate antibiotics are prescribed, as the benefits of continued breastfeeding outweigh the minimal risks of antibiotic exposure through breast milk. 2, 4

Common Pitfalls to Avoid

• Do not unnecessarily discontinue breastfeeding when prescribing safe antibiotics—short courses of appropriate antibiotics are commonly used with no evidence of harmful effects. 2
• Avoid prescribing long-acting formulations when shorter-acting alternatives are available, as drugs with short half-lives minimize the risk of accumulation in the infant. 6
• Do not assume that a drug safe during pregnancy is automatically safe during breastfeeding—these are distinct considerations. 7