What is the recommended treatment for a patient with tonsillitis, considering their age, weight, and medical history, including any allergies or previous reactions to medications?

Treatment of Tonsillitis

For acute tonsillitis, test before treating with rapid antigen detection testing (RADT) or throat culture for Group A Streptococcus (GAS), and if positive, treat with penicillin V or amoxicillin for 10 days; if negative, provide supportive care only. 1, 2

Diagnostic Algorithm

Confirm bacterial versus viral etiology before any antibiotic consideration:

• Obtain throat swab for RADT and/or culture from posterior pharynx before initiating antibiotics 3, 1, 2
• Bacterial (GAS) tonsillitis presents with: sudden onset sore throat, fever >38.3°C (101°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 3, 1, 2
• Viral tonsillitis presents with: cough, rhinorrhea, hoarseness, and typically lacks high fever, exudates, and significant lymphadenopathy 4
• Use clinical scoring (Centor, McIsaac, or FeverPAIN) to estimate probability of bacterial infection when testing is not immediately available 5

Medical Treatment for Confirmed GAS Tonsillitis

First-line antibiotic therapy:

• Penicillin V for 10 days is the gold standard treatment 1, 2
• Amoxicillin for 10 days is an acceptable first-line alternative 1, 2, 6
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even if symptoms resolve earlier 1, 2, 6

For penicillin-allergic patients:

• Non-anaphylactic allergy: use first-generation cephalosporins for 10 days 1
• Anaphylactic allergy: use clindamycin, azithromycin (5 days), or clarithromycin (10 days) 1, 7
• Macrolides offer more convenient dosing with clarithromycin twice daily and azithromycin once daily 7

Dosing for amoxicillin (from FDA label):

• Adults and children >40 kg: 500 mg every 12 hours or 250 mg every 8 hours for mild/moderate; 875 mg every 12 hours or 500 mg every 8 hours for severe 6
• Children ≥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; 45 mg/kg/day divided every 12 hours or 40 mg/kg/day divided every 8 hours for severe 6
• Children <3 months: maximum 30 mg/kg/day divided every 12 hours due to immature renal function 6

Supportive Care for All Patients

Pain and symptom management:

• Provide acetaminophen or ibuprofen for pain and fever control 2, 4
• Ensure adequate hydration throughout illness 4
• Counsel patients and caregivers about the importance of managing and reassessing pain 3
• Take amoxicillin at the start of meals to minimize gastrointestinal intolerance 6

Surgical Treatment: Tonsillectomy Indications

Watchful waiting is strongly recommended if episodes are:

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

Tonsillectomy may be considered when meeting Paradise criteria:

• ≥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 3, 1, 2
• Each episode must be documented with: temperature >38.3°C, cervical adenopathy, tonsillar exudate, OR positive GAS test 3, 2

Modifying factors that may favor tonsillectomy despite not meeting frequency criteria:

• Multiple antibiotic allergies/intolerance 3
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) 3
• History of >1 peritonsillar abscess 3

Important surgical considerations:

• Do NOT administer perioperative antibiotics for tonsillectomy 3
• Administer single intraoperative dose of IV dexamethasone 3
• Use ibuprofen and/or acetaminophen for postoperative pain 3
• Never use codeine in children <12 years after tonsillectomy (FDA black box warning) 3

Recurrent Tonsillitis Management

For patients with recurrent acute pharyngo-tonsillitis (RAPT):

• Clindamycin and amoxicillin-clavulanate show superior microbiological eradication and reduction in future episodes compared to penicillin 8
• These agents may be considered in patients with RAPT who have contraindications to tonsillectomy 8
• However, penicillin failure rates have increased from 2-10% historically to approximately 30% currently, primarily due to non-compliance with 10-day regimens 9

Critical Pitfalls to Avoid

Never initiate antibiotics without confirming GAS infection through testing - the majority of tonsillitis cases are viral and do not benefit from antibiotics 1, 2, 4

Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis (except azithromycin 5-day course) - this increases treatment failure risk 1, 2

Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 2

Never perform tonsillectomy without meeting appropriate frequency and documentation criteria - spontaneous improvement commonly occurs with watchful waiting 3, 2

Do not treat positive GAS tests in patients with viral symptoms - these are likely chronic carriers experiencing concurrent viral infection 4

Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1

Follow-Up Considerations

• If symptoms persist despite appropriate therapy, consider: medication non-compliance, chronic GAS carriage with intercurrent viral infection, or need for alternative antibiotics 1
• Treatment should continue for minimum 48-72 hours beyond symptom resolution or evidence of bacterial eradication 3, 6
• For tonsillectomy patients, follow up to document presence or absence of bleeding within 24 hours (primary) and after 24 hours (secondary) 3