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

Management of Acute Tonsillitis

Diagnostic Confirmation Before Treatment

Always confirm Group A Streptococcus (GAS) infection with rapid antigen detection testing (RADT) and/or throat culture before prescribing antibiotics—never initiate antibiotics based on clinical presentation alone. 1, 2

• Bacterial tonsillitis presents with sudden onset sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and notably absence of cough. 1, 2
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy—these cases require only supportive care. 1, 3
• Use clinical scoring systems (Centor, McIsaac, FeverPAIN) to estimate bacterial probability, but always confirm with testing before antibiotics. 2, 4

First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis

Prescribe penicillin V orally for 10 days as the gold standard treatment, or amoxicillin for 10 days as an equivalent alternative. 1, 2

• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis—never prescribe shorter courses despite symptom resolution. 1, 2, 5
• Penicillin V dosing: standard adult dosing per guidelines. 6
• Amoxicillin dosing: For pediatric patients ≥3 months and <40 kg, use 45 mg/kg/day in divided doses every 12 hours or 40 mg/kg/day in divided doses every 8 hours for pharyngitis/tonsillitis; for patients ≥40 kg, use 875 mg every 12 hours or 500 mg every 8 hours. 5

Management of Penicillin Allergy

For non-anaphylactic penicillin allergy, use first-generation cephalosporins (cephalexin, cefadroxil) for 10 days. 6, 2

• For anaphylactic (Type I hypersensitivity) penicillin allergy, prescribe clindamycin, azithromycin, or clarithromycin. 6, 2
• Azithromycin dosing for pediatric pharyngitis/tonsillitis: 12 mg/kg once daily for 5 days (maximum 500 mg/day). 7
• Erythromycin is also acceptable for penicillin-allergic patients. 6

Symptomatic Management

Prescribe ibuprofen and/or acetaminophen as first-line analgesia for pain and fever control in all patients with acute tonsillitis. 2

• Consider a single dose of dexamethasone for additional pain relief in severe cases, particularly when combined with antibiotics. 2
• Address pain management during the first 24 hours regardless of antibiotic use. 6

Management of Recurrent Tonsillitis

Use Paradise criteria to guide tonsillectomy decisions: consider surgery only if ≥7 documented episodes in the past year, OR ≥5 per year for 2 consecutive years, OR ≥3 per year for 3 consecutive years. 1, 2

• Each documented episode must include temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test. 8
• Watchful waiting is appropriate if episodes are fewer than these thresholds, as many cases resolve spontaneously. 1, 2
• For recurrent documented GAS tonsillitis not meeting surgical criteria, consider alternative antibiotic regimens: clindamycin 20-30 mg/kg/day in three divided doses for 10 days, amoxicillin-clavulanate, or penicillin with rifampin. 6, 8, 9

Distinguishing Chronic Carriers from Active Infection

Patients with recurrent positive GAS tests may be chronic carriers experiencing viral infections rather than true bacterial tonsillitis—do not treat asymptomatic positive tests. 6, 8

• Carriers harbor GAS without active infection; routine antibiotic treatment is not beneficial in this population. 8
• Consider carrier eradication with clindamycin only during community outbreaks of acute rheumatic fever, poststreptococcal glomerulonephritis, or with personal/family history of rheumatic fever. 8

Follow-Up Recommendations

Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy. 1, 2

• If symptoms persist despite appropriate therapy, reassess for medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics. 6, 2
• If the patient fails to respond within 48-72 hours, confirm AOM diagnosis and consider changing antibacterial agents. 6

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing—most tonsillitis cases are viral and do not require antibiotics. 1, 2
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS. 1, 2
• Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis, as this increases treatment failure risk and complications. 1, 2
• Never perform tonsillectomy without proper documentation meeting Paradise criteria, as surgical benefits are modest and time-limited. 1, 2
• Never treat asymptomatic positive GAS tests, as this likely represents chronic carriage rather than active infection. 1, 8