What is the best course of action for a patient with unilateral tonsillitis and a grey, pus-covered tonsil, currently being treated with clindamycin?

Monitoring Unilateral Tonsillitis on Clindamycin

Continue clindamycin for the full 10-day course and monitor closely for clinical improvement within 48-72 hours, but maintain heightened vigilance for peritonsillar abscess or other complications given the unilateral presentation with grey exudate.

Immediate Clinical Assessment

• Unilateral presentation with grey, pus-covered tonsil raises concern for peritonsillar abscess or other suppurative complications, which require different management than simple bacterial tonsillitis 1, 2
• Assess for trismus (difficulty opening mouth), uvular deviation away from the affected side, "hot potato voice," and severe dysphagia—all suggesting abscess formation 2
• If any signs of abscess are present, imaging (CT with contrast or ultrasound) and possible ENT consultation for drainage are indicated 2

Clindamycin Efficacy for This Presentation

• Clindamycin 300 mg three times daily for 10 days is highly effective for recurrent or treatment-resistant GAS tonsillitis, with bacteriologic eradication rates of 97.9% and clinical cure rates of 92.6% at day 12 3, 4
• Clindamycin achieves adequate tissue concentrations in tonsillar tissue (0.6-0.8 mcg/g after 7-9 hours) that exceed the MIC for 91.7% of strains 5
• For patients with treatment failure after penicillin, clindamycin protects against recurrence for at least 3 months and may prevent need for tonsillectomy 4

Monitoring Timeline and Expected Response

• Clinical improvement should be evident within 48-72 hours of starting appropriate antibiotic therapy 6
• If fever, pain, and dysphagia are not improving by 72 hours, reassess for:
  • Medication non-compliance 1, 7
  • Abscess formation requiring drainage 2
  • Alternative diagnosis (infectious mononucleosis, diphtheria, or malignancy in unilateral cases) 2

Critical Red Flags Requiring Immediate Escalation

• Worsening unilateral swelling, increasing trismus, or respiratory compromise warrant immediate ENT evaluation 2
• Development of "hot potato voice" or drooling suggests abscess 2
• Inability to swallow secretions or maintain hydration requires hospitalization 8

Completion of Therapy

• The full 10-day course must be completed even if symptoms resolve earlier, to maximize bacterial eradication and prevent complications like rheumatic fever 1, 7
• Do not obtain follow-up throat cultures if the patient becomes asymptomatic after completing therapy, as this is not recommended 1, 7

Important Caveats

• Grey membrane on tonsils can also indicate diphtheria or infectious mononucleosis—ensure vaccination history is current and consider monospot if patient has significant fatigue, posterior cervical adenopathy, or hepatosplenomegaly 2
• Clindamycin carries risk of Clostridioides difficile infection; counsel patient to report watery or bloody diarrhea immediately, even up to 2 months after completing therapy 9
• Unilateral presentation is atypical for simple GAS pharyngitis and should prompt consideration of other diagnoses if no improvement occurs 2