What is the recommended management for a patient with tonsillitis, considering potential complications and past medical history of conditions such as rheumatic fever?

Management of Tonsillitis

Diagnostic Approach

Test all patients with symptoms suggestive of bacterial tonsillitis using rapid antigen detection test (RADT) and/or throat culture before prescribing antibiotics. 1 Look specifically for sudden onset sore throat, fever >38°C (101°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough—these features distinguish bacterial from viral causes. 1, 2, 3

• Do not treat based on clinical presentation alone, as 70-95% of tonsillitis cases are viral and cannot be reliably distinguished from bacterial causes without testing. 4
• Only prescribe antibiotics when Group A Streptococcus (GAS) is confirmed by positive RADT or culture. 1
• In adults, a negative RADT alone may be sufficient without culture backup, but in children and adolescents, confirm negative RADT results with throat culture due to lower test sensitivity. 1

First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis

Prescribe penicillin V 250 mg twice or three times daily for children (or 500 mg twice daily for adolescents/adults) for 10 days as first-line therapy. 1, 2 Alternatively, amoxicillin 50 mg/kg once daily (maximum 1000 mg) for 10 days is equally effective and may improve compliance. 1, 3

• The full 10-day course is essential to maximize bacterial eradication and prevent acute rheumatic fever, particularly in patients with prior rheumatic fever history. 1, 2
• For patients <27 kg, use benzathine penicillin G 600,000 units intramuscularly as a single dose; for patients ≥27 kg, use 1,200,000 units intramuscularly when compliance with oral therapy is questionable. 1

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy, prescribe cephalexin 20 mg/kg/dose twice daily (maximum 500 mg/dose) or cefadroxil 30 mg/kg once daily (maximum 1 g) for 10 days. 1, 3 Avoid cephalosporins in patients with immediate-type hypersensitivity reactions to penicillin. 1

• For anaphylactic penicillin allergy, use clindamycin 7 mg/kg/dose three times daily (maximum 300 mg/dose) for 10 days. 1, 2
• Azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days or clarithromycin 7.5 mg/kg/dose twice daily (maximum 250 mg/dose) for 10 days are acceptable alternatives, though macrolide resistance varies geographically. 1, 3

Supportive Care

Provide analgesics for all patients regardless of bacterial confirmation: acetaminophen, ibuprofen, or aspirin (in adults) for pain and fever control. 1, 2 Throat lozenges may provide additional symptomatic relief. 1

• Ensure adequate hydration and educate patients that viral tonsillitis typically resolves within one week without antibiotics. 1, 2
• Antibiotics shorten symptom duration by only 1-2 days (number needed to treat = 6 at 3 days), but are critical for preventing rheumatic fever and suppurative complications. 1

Management of Recurrent Tonsillitis

Recommend watchful waiting if episodes are fewer than 7 in the past year, fewer than 5 per year for 2 consecutive years, or fewer than 3 per year for 3 consecutive years. 2, 3, 4 Spontaneous improvement commonly occurs, with control groups showing reduction to only 0.3-1.17 episodes per year without surgery. 2

• Consider tonsillectomy only when recurrent episodes meet the Paradise criteria with proper documentation: each episode must include temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test. 2, 3, 5
• For patients with multiple recurrent episodes despite appropriate antibiotic therapy, consider alternative regimens: clindamycin 20-30 mg/kg/day in 3 divided doses for 10 days, amoxicillin-clavulanate 40 mg/kg/day in 3 divided doses for 10 days, or benzathine penicillin G with rifampin 20 mg/kg/day for 4 days. 1, 5

Special Considerations for Patients with Rheumatic Fever History

Patients with prior rheumatic fever require continuous antimicrobial prophylaxis to prevent recurrence, not just treatment of acute episodes. 1 This is the only indication for continuous prophylaxis in GAS carriers. 1

• Treat acute symptomatic episodes in these patients with standard 10-day antibiotic courses as above, ensuring complete eradication. 1
• Do not shorten antibiotic duration in this high-risk population. 1, 2

Management of GAS Carriers

Do not treat asymptomatic GAS carriers or those with positive tests during viral upper respiratory infections. 1 Carriers harbor GAS without active infection, are unlikely to spread infection, and face minimal risk of complications including rheumatic fever. 1, 5

• Consider carrier eradication treatment only during community outbreaks of acute rheumatic fever, poststreptococcal glomerulonephritis, or in patients with personal/family history of rheumatic fever. 1, 5
• When carrier eradication is indicated, use clindamycin 20-30 mg/kg/day in 3 divided doses (maximum 300 mg per dose) for 10 days. 1, 5

Critical Pitfalls to Avoid

• Never prescribe antibiotics without confirming GAS infection through testing—this leads to unnecessary antibiotic exposure and resistance. 1, 2
• Never use courses shorter than 10 days for penicillin or amoxicillin—this increases treatment failure risk and does not adequately prevent rheumatic fever. 1, 2
• Never perform routine follow-up throat cultures in asymptomatic patients who completed appropriate therapy—positive results likely represent carriage, not treatment failure. 1
• Never recommend tonsillectomy solely to reduce GAS pharyngitis frequency without meeting established Paradise criteria with proper documentation. 1, 2
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective and appropriate. 1, 2