What is the appropriate treatment for a child or young adult with pustular tonsillitis, possibly with a history of recurrent tonsillitis or a weakened immune system?

Treatment of Pustular Tonsillitis in Children and Young Adults

For pustular tonsillitis, test for group A beta-hemolytic streptococcus (GABHS) using rapid antigen detection or throat culture, and if positive, treat with penicillin or amoxicillin as first-line therapy. 1

Diagnostic Approach

The presence of tonsillar exudate (pustules) is a key clinical feature that increases the likelihood of GABHS infection and warrants testing. 1

Apply the modified Centor criteria to guide testing decisions:

• Tonsillar exudate (pustules)
• Tender anterior cervical adenopathy
• Fever >38.3°C (101°F)
• Absence of cough

1

• Patients with ≥3 Centor criteria should undergo rapid antigen detection testing or throat culture before prescribing antibiotics 1
• If the rapid test is positive, proceed immediately with antibiotic therapy 1
• If negative but clinical suspicion remains high, send a throat culture for confirmation 1

Antibiotic Treatment (When GABHS Confirmed)

First-line therapy: Penicillin or amoxicillin 1, 2

Dosing for amoxicillin (FDA-approved):

• Adults and children ≥40 kg: 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 2
• Children ≥3 months and <40 kg: 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 2
• Duration: Minimum 10 days for GABHS to prevent acute rheumatic fever 2

Alternative antibiotics for recurrent infections:

• In patients with recurrent acute pharyngo-tonsillitis, clindamycin or amoxicillin-clavulanate show superior microbiological eradication and reduction in future episodes compared to penicillin 3
• These alternatives are particularly useful in patients with multiple antibiotic allergies or treatment failures 4, 5

When Antibiotics Are NOT Indicated

Do not prescribe antibiotics if:

• Rapid strep test and throat culture are negative 1
• Patient has <3 Centor criteria and testing is not performed 1
• Clinical features suggest viral etiology (cough, nasal congestion, conjunctivitis, hoarseness, or oropharyngeal ulcers/vesicles) 1

Supportive Care

• Pain management: Ibuprofen and acetaminophen for pain control 5
• Avoid codeine in children <12 years 5
• Take amoxicillin at the start of a meal to minimize gastrointestinal intolerance 2

Red Flags Requiring Urgent Evaluation

Seek immediate medical attention for:

• Difficulty swallowing, drooling, or neck tenderness suggesting peritonsillar abscess, parapharyngeal abscess, or Lemierre syndrome 1
• Persistent high fever >38.3°C despite treatment 5
• Development of "hot potato" voice or severe pain with inability to open mouth (peritonsillar abscess) 5
• Adolescents and young adults are at particular risk for Fusobacterium necrophorum infection and Lemierre syndrome 1

Documentation and Follow-Up

Each episode must be thoroughly documented with:

• Temperature measurement 5, 6
• Presence of cervical adenopathy 5, 6
• Results of rapid antigen detection testing or throat culture 5, 6
• School absences and quality of life impact 5

This documentation is critical for determining whether the patient meets criteria for tonsillectomy if infections become recurrent. 5

When to Consider Tonsillectomy

Tonsillectomy should be considered only if the patient meets Paradise criteria:

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

4, 5, 1, 7

Each episode must include:

• Temperature >38.3°C
• Cervical adenopathy
• Tonsillar exudate (pustules), OR
• Positive GABHS test

4, 1, 6

Modifying factors that may favor earlier tonsillectomy:

• Multiple antibiotic allergies or intolerance 4, 5
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and adenitis) 4, 5
• History of >1 peritonsillar abscess 5
• Weakened immune system or pattern of very severe/poorly tolerated episodes 4

Watchful waiting is strongly recommended for patients not meeting these criteria, as spontaneous improvement is common. 5, 1, 6, 8, 7

Special Considerations for Immunocompromised Patients

Patients with weakened immune systems who experience severe or poorly tolerated throat episodes may warrant consideration for tonsillectomy even if they don't strictly meet Paradise criteria, as this represents a modifying factor based on individual features of illness. 4 However, the risks and benefits of surgery must be carefully weighed in this population. 4