What is the recommended treatment for a patient with acute tonsillitis with suppurations, assuming no penicillin allergy or history of recurrent tonsillitis?

Treatment of Acute Tonsillitis with Suppurations

For acute tonsillitis with suppurations (presumed bacterial etiology with exudates), prescribe penicillin V or amoxicillin for 10 days as first-line therapy, with the primary goals being prevention of suppurative complications (peritonsillar abscess, cervical lymphadenitis) and acute rheumatic fever. 1

First-Line Antibiotic Regimens (No Penicillin Allergy)

Penicillin V remains the gold standard due to its narrow spectrum, proven efficacy, and low cost 1:

• Children: 250 mg twice or three times daily for 10 days 1
• Adolescents and adults: 250 mg four times daily OR 500 mg twice daily for 10 days 1

Amoxicillin is an equally effective alternative with better compliance due to simpler dosing 1, 2:

• Children: 50 mg/kg once daily (maximum 1000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
• Adults: 500 mg every 12 hours OR 875 mg every 12 hours for 10 days 2

Benzathine penicillin G intramuscular is an option when compliance is a concern 1:

• <27 kg: 600,000 units as a single dose 1
• ≥27 kg: 1,200,000 units as a single dose 1

Alternative Regimens for Penicillin Allergy

For non-anaphylactic penicillin allergy, first-generation cephalosporins are preferred 1:

• Cephalexin: 20 mg/kg/dose twice daily (maximum 500 mg/dose) for 10 days 1
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1

For anaphylactic penicillin allergy or immediate-type hypersensitivity 1:

• Clindamycin: 7 mg/kg/dose three times daily (maximum 300 mg/dose) for 10 days 1
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 3
• Clarithromycin: 7.5 mg/kg/dose twice daily (maximum 250 mg/dose) for 10 days 1

Important caveat: Macrolide resistance (azithromycin, clarithromycin) varies geographically and temporally, making them less reliable than penicillins or clindamycin 1.

Critical Duration Requirements

The full 10-day course is mandatory for penicillins, cephalosporins, and clindamycin to maximize bacterial eradication and prevent acute rheumatic fever 1, 2. Short courses (5 days) of standard-dose penicillin are less effective for Group A Streptococcus eradication and should be avoided 1, 4. The only exception is azithromycin, which requires only 5 days due to its prolonged tissue half-life 1, 3.

Adjunctive Symptomatic Management

All patients should receive symptomatic relief regardless of antibiotic therapy 1:

• NSAIDs (ibuprofen) or acetaminophen for pain and fever control 1, 5
• Avoid aspirin in children due to Reye's syndrome risk 1
• Corticosteroids are not recommended for routine Group A Streptococcal pharyngitis 1

Key Clinical Pitfalls to Avoid

Do not prescribe antibiotics without confirming bacterial infection through rapid antigen detection testing (RADT) or throat culture, as viral tonsillitis (which also presents with exudates in some cases like EBV) does not benefit from antibiotics 5, 4. However, the presence of suppurations (tonsillar exudates) combined with fever, tender anterior cervical lymphadenopathy, and absence of cough strongly suggests bacterial etiology 1, 4.

Do not use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed Group A Streptococcus 5, 4. This prevents unnecessary resistance development and adverse effects.

Do not perform routine follow-up throat cultures in asymptomatic patients who have completed appropriate antibiotic therapy 6, 4. Post-treatment testing is generally not recommended unless specific risk factors exist 1.

When Suppurations Suggest Peritonsillar Abscess

If suppurations are accompanied by severe unilateral tonsillar swelling, uvular deviation, trismus, or "hot potato voice," consider peritonsillar abscess requiring urgent ENT evaluation for possible drainage 1. In such cases, broader coverage with amoxicillin-clavulanate or clindamycin may be warranted to cover anaerobes and beta-lactamase producing organisms 7.

Management of Treatment Failure

If symptoms persist or recur within 2 weeks despite appropriate therapy, consider alternative regimens targeting beta-lactamase producing organisms 6, 7:

• Clindamycin: 20-30 mg/kg/day in three divided doses (maximum 300 mg/dose) for 10 days 6
• Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in three doses (maximum 2000 mg amoxicillin/day) for 10 days 6

Alternatively, the patient may be a chronic Group A Streptococcus carrier experiencing intercurrent viral infections rather than recurrent bacterial tonsillitis 1, 6, 4.