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 confirmed bacterial (Group A Streptococcus) tonsillitis, prescribe penicillin V or amoxicillin for a full 10-day course after confirming diagnosis with rapid antigen detection testing or throat culture. 1, 2, 3

Diagnostic Approach: Test Before Treating

• Always obtain microbiological confirmation before initiating antibiotics using rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS), as 70-95% of tonsillitis cases are viral and do not require antibiotics. 1, 4

• Bacterial tonsillitis presents with sudden onset sore throat, fever >38.3°C (101°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 5, 1, 2

• Obtain the throat culture specimen from the posterior pharynx and both tonsils before starting any antibiotics, requiring at least 10 colonies of group A β-hemolytic streptococci on sheep's-blood agar for confirmation. 5

First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis

Penicillin V for 10 days remains the gold standard treatment, with amoxicillin as an equally acceptable first-line alternative. 1, 2, 3

Standard Dosing Regimens:

• Adults and children ≥40 kg: Amoxicillin 500 mg every 12 hours OR 250 mg every 8 hours for mild/moderate infections; 875 mg every 12 hours OR 500 mg every 8 hours for severe infections. 3

• Children ≥3 months and <40 kg: Amoxicillin 25 mg/kg/day divided every 12 hours OR 20 mg/kg/day divided every 8 hours for mild/moderate infections; 45 mg/kg/day divided every 12 hours OR 40 mg/kg/day divided every 8 hours for severe infections. 3

• Children <3 months: Maximum 30 mg/kg/day divided every 12 hours due to incompletely developed renal function. 3

• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even if symptoms resolve earlier. 1, 2, 5

Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy: Use first-generation cephalosporins. 1

For anaphylactic penicillin allergy: Use clindamycin, azithromycin, or clarithromycin. 1

• Clarithromycin is dosed twice daily for 10 days; azithromycin once daily for 5 days due to prolonged tissue half-life. 6

• Newer macrolides offer lower rates of gastrointestinal side effects compared to erythromycin. 6

Symptomatic Management

• Prescribe ibuprofen and/or acetaminophen for pain and fever control at the start of treatment. 1, 2

• Consider a single dose of dexamethasone for additional pain relief in severe cases, particularly when combined with antibiotics. 1

• Ensure adequate hydration and counsel patients/caregivers about the importance of managing and reassessing pain throughout the illness. 2

Surgical Management: When to Consider Tonsillectomy

Strongly recommend watchful waiting if episodes are fewer than 7 in the past year, fewer than 5 per year for 2 years, or fewer than 3 per year for 3 years. 5, 1, 2

Tonsillectomy may be recommended when meeting Paradise criteria with proper documentation: 5, 1, 2

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

Each documented episode must include: 5, 1, 2

• Temperature >38.3°C (101°F), AND
• Cervical adenopathy, tonsillar exudate, OR positive test for GAS

Modifying Factors That May Favor Earlier Tonsillectomy:

• Multiple antibiotic allergies/intolerance 5
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 5
• History of >1 peritonsillar abscess 5

Perioperative Considerations if Tonsillectomy Performed:

• Do NOT administer perioperative antibiotics to children undergoing tonsillectomy. 5

• Administer a single intraoperative dose of IV dexamethasone to reduce postoperative pain and nausea. 5

• Prescribe ibuprofen and/or acetaminophen for postoperative pain control. 5

• Never prescribe codeine or any codeine-containing medication to children <12 years after tonsillectomy due to FDA black box warning. 5

Follow-Up and Monitoring

• Do NOT perform routine follow-up throat cultures in asymptomatic patients who completed appropriate antibiotic therapy. 1, 7

• If symptoms persist despite appropriate therapy, consider medication non-compliance, chronic GAS carriage with intercurrent viral infections, or antibiotic resistance requiring alternative therapy. 1, 8

• Treatment failure rates with penicillin have increased from 2-10% historically to approximately 30% currently, primarily due to non-compliance with the 10-day regimen. 8

Critical Pitfalls to Avoid

Never initiate antibiotics without confirming GAS infection through testing, as this contributes to unnecessary antibiotic use in the majority of viral cases. 1, 2

Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis (except azithromycin 5-day course), as this increases treatment failure risk and does not prevent rheumatic fever. 1, 2, 5

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, as spontaneous improvement commonly occurs with watchful waiting. 1, 2

Never withhold antibiotics altogether in confirmed bacterial tonsillitis, as this increases risk of suppurative complications and rheumatic fever. 4, 9