What is the treatment for exudative tonsillitis, particularly in patients with a history of recurrent tonsillitis?

Treatment of Exudative Tonsillitis

For acute exudative tonsillitis, confirm Group A Streptococcus (GAS) with rapid antigen detection testing or throat culture before initiating antibiotics, then treat with penicillin V or amoxicillin for 10 days; for patients with recurrent tonsillitis meeting Paradise criteria (≥7 episodes in 1 year, ≥5 per year for 2 years, or ≥3 per year for 3 years), tonsillectomy should be considered. 1, 2

Acute Episode Management

Diagnostic Confirmation

• Always test before treating with rapid antigen detection testing (RADT) and/or throat culture for GAS before initiating any antibiotic therapy, as most cases (70-95%) are viral in origin 2, 3, 4
• Use clinical scoring systems (Centor, McIsaac, or FeverPAIN) to estimate bacterial probability, with scores ≥3 suggesting higher likelihood of GAS 2, 3
• Bacterial tonsillitis presents with sudden onset sore throat, fever >38.3°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2

First-Line Antibiotic Treatment

• Penicillin V for 10 days remains the gold standard for confirmed GAS tonsillitis 1, 2, 4
• Amoxicillin is an acceptable alternative with equivalent efficacy 2, 5
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even if symptoms resolve earlier 2

Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: use first-generation cephalosporins 2
• For anaphylactic allergy: use clindamycin, azithromycin, or clarithromycin 1, 2
• Azithromycin demonstrates 95% bacteriologic eradication at Day 14 and 77% at Day 30, compared to 73% and 63% respectively for penicillin V 6

Symptomatic Management

• Ibuprofen and/or paracetamol as first-line analgesia for pain and fever control 2
• A single dose of dexamethasone may provide additional pain relief in severe cases, particularly when combined with antibiotics 2

Recurrent Tonsillitis Management

Watchful Waiting Criteria

• 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 1, 7, 2, 4
• Watchful waiting does not mean inaction—closely monitor and accurately document all episodes with symptoms, physical findings, test results, and quality of life impacts 1, 7
• Many cases improve spontaneously: untreated children experienced only 1.17 episodes in the first year after observation, 1.03 in the second year, and 0.45 in the third year 7

Paradise Criteria for Tonsillectomy

Tonsillectomy should be considered when ALL of the following are met: 1, 7

• Frequency threshold: ≥7 episodes in the preceding year, OR ≥5 episodes per year in each of the preceding 2 years, OR ≥3 episodes per year in each of the preceding 3 years
• Clinical features: Each episode must include temperature >38.3°C, OR cervical lymphadenopathy (tender nodes or >2 cm), OR tonsillar exudate, OR positive test for GAS 1, 7
• Treatment documentation: Antibiotics administered in conventional dosage for proven or suspected streptococcal episodes 1, 7
• Proper documentation: Each episode substantiated by contemporaneous notation in clinical record 1, 7

Modifying Factors Favoring Earlier Surgery

Tonsillectomy may be considered even without meeting strict Paradise criteria when: 7

• Multiple antibiotic allergies or intolerance exist
• PFAPA syndrome is present
• History of >1 peritonsillar abscess
• Significant impact on growth and development

Treatment for Recurrent Episodes

For patients with multiple recurrent episodes who do not meet surgical criteria, certain antibiotics achieve higher eradication rates than penicillin: 1, 8

Preferred regimens for recurrent tonsillitis: 1

• Clindamycin: Children 20-30 mg/kg/day in 3 divided doses for 10 days; Adults 600 mg/day in 2-4 divided doses for 10 days
• Amoxicillin-clavulanate: Children 40 mg/kg/day in 3 divided doses for 10 days; Adults 500 mg twice daily for 10 days
• Benzathine penicillin G (IM): Single dose, useful when compliance is questionable

These regimens are superior to penicillin because they eradicate beta-lactamase-producing bacteria (BLPB) that "shield" GAS from penicillin, which are recovered from over 75% of tonsils in patients with recurrent infection 8, 9

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing—this leads to unnecessary antibiotic use in the 70-95% of cases that are viral 2, 3
• Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis, as this fails to prevent rheumatic fever 2
• Never perform tonsillectomy without meeting appropriate frequency and documentation criteria, as only 17% of patients reporting recurrent episodes actually have adequate documentation 1
• Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1, 2
• Avoid continuous long-term antimicrobial prophylaxis to prevent recurrent episodes, except for patients with a history of rheumatic fever 1
• Do not use macrolides or cephalosporins as first-line treatment for recurrent episodes, as there are insufficient data supporting their efficacy in this specific circumstance 1

When Treatment Fails

If symptoms persist despite appropriate therapy, consider: 2

• Medication non-compliance (most common)
• Chronic GAS carriage with intercurrent viral infections
• Need for alternative antibiotics targeting beta-lactamase-producing organisms 8, 9