What is the recommended treatment for a patient with acute tonsillitis, considering potential allergies and history of recurrent episodes?

Treatment of Acute Tonsillitis

For acute tonsillitis, confirm Group A Streptococcus (GAS) infection with 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—never shorter—to prevent rheumatic fever and maximize bacterial eradication. 1, 2

Diagnostic Approach

Before prescribing any antibiotic, testing is mandatory to differentiate bacterial from viral tonsillitis 1, 2:

• Use RADT and/or throat culture to confirm GAS infection before starting antibiotics 1, 2
• Apply clinical scoring systems (Centor, McIsaac, or FeverPAIN) to estimate probability of bacterial infection 3
• Look for these specific findings suggesting bacterial tonsillitis: sudden onset sore throat, fever >38°C (>38.3°C for documentation), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 4, 1, 2
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy 2

Critical pitfall: Never initiate antibiotics without confirming GAS infection through testing, as the majority of tonsillitis cases are viral 2, 5.

First-Line Antibiotic Treatment for Confirmed GAS

Penicillin V for 10 days is the gold standard for confirmed bacterial tonsillitis 1, 2:

• Penicillin V: Standard first-line treatment for 10 days 1, 2
• Amoxicillin: Acceptable alternative first-line option for 10 days 1, 2
• Dosing for amoxicillin in pediatric patients ≥3 months and <40 kg: 25 mg/kg/day divided every 12 hours or 20 mg/kg/day divided every 8 hours for mild/moderate infections 6
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even if symptoms resolve earlier 4, 1, 2

Critical pitfall: Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis—this increases treatment failure risk and complications 4, 1, 7.

Management of Penicillin Allergy

The approach depends on allergy type 4, 2:

• Non-anaphylactic penicillin allergy: Use first-generation cephalosporins (cefdinir, cefpodoxime, or cefuroxime) 4, 2
• Anaphylactic or Type I hypersensitivity: Use clindamycin, azithromycin, or clarithromycin 4, 2
• Erythromycin is also suitable for penicillin-allergic patients 4

For azithromycin in pediatric pharyngitis/tonsillitis (age ≥2 years): 12 mg/kg once daily for 5 days 8.

Recurrent Tonsillitis Management

Initial Episodes of Recurrence

For single recurrent episodes shortly after completing appropriate therapy 4:

• Retreat with any first-line regimen (penicillin V or amoxicillin for 10 days) 4
• Consider intramuscular benzathine penicillin G if compliance with oral medications is questionable 4
• Do not perform routine post-treatment cultures unless patient remains symptomatic 4, 7

Multiple Recurrent Episodes

When multiple episodes occur over months to years, distinguish between true recurrent GAS infections versus chronic GAS carrier with intercurrent viral infections 4, 7:

• True recurrent GAS: Multiple bona fide bacterial infections requiring aggressive treatment 7
• Chronic carrier: Patient colonized with GAS who experiences viral pharyngitis that tests positive for GAS but lacks active immunologic response 7
• Carriers lack rising anti-streptococcal antibody titers and are at very low risk for complications 7

For confirmed multiple recurrent bacterial episodes, use agents with high pharyngeal eradication rates 4, 7:

• Clindamycin: 20-30 mg/kg/day divided into 3 doses for 10 days (children) or 600 mg/day divided into 2-4 doses for 10 days (adults) 4, 7
• Amoxicillin-clavulanate: 40 mg/kg/day divided into 3 doses for 10 days 4
• These regimens achieve superior microbiological eradication compared to penicillin in recurrent cases 9

Critical pitfall: Do not routinely test or treat asymptomatic household contacts unless "Ping-Pong spread" is suspected with simultaneous family infections 4, 7.

Tonsillectomy Indications

Tonsillectomy should be considered only when meeting Paradise criteria with proper documentation 1, 2, 7:

• ≥7 documented episodes in the past year, OR
• ≥5 documented episodes per year for 2 consecutive years, OR
• ≥3 documented episodes per year for 3 consecutive years 1, 2, 7

Each documented episode must include: temperature >38.3°C, cervical adenopathy, tonsillar exudate, OR positive test for GAS 2, 7.

Watchful waiting is appropriate if episodes fall below these thresholds, as spontaneous improvement commonly occurs (control groups showed reduction to only 0.3-1.17 episodes per year without surgery) 1.

Critical pitfall: Never perform tonsillectomy without meeting appropriate frequency and documentation criteria 2, 7. The Infectious Diseases Society of America does not recommend tonsillectomy solely to reduce GAS pharyngitis frequency 7.

Supportive Care

Pain management is essential regardless of antibiotic use 4, 1:

• Provide adequate analgesia with acetaminophen or ibuprofen for pain and fever control 1
• Ensure adequate hydration 1, 5
• Address pain especially during the first 24 hours of illness 4

Follow-Up

Routine follow-up throat cultures are not indicated for asymptomatic patients who completed appropriate antibiotic therapy 4, 2, 7.

If symptoms persist despite appropriate therapy, consider 2:

• Medication non-compliance
• Chronic GAS carriage with intercurrent viral infections
• Need for alternative antibiotics