What is the most appropriate treatment for a febrile 7‑year‑old child with exudative tonsillitis: observation, 10‑day amoxicillin, 5‑day azithromycin, or intramuscular penicillin?

Treatment of Febrile 7-Year-Old with Exudative Tonsillitis

For a 7-year-old child with fever and exudative tonsillitis, prescribe 10-day amoxicillin (Option B) at 40–50 mg/kg/day divided into two doses (maximum 1000 mg/dose), provided Group A Streptococcus is confirmed by rapid antigen test or throat culture. 1, 2

Why 10-Day Amoxicillin is the Correct Answer

Amoxicillin remains the drug of choice for streptococcal pharyngitis in children due to proven efficacy, narrow spectrum, safety, and low cost, with no documented penicillin resistance in Group A Streptococcus anywhere in the world. 1, 2 The full 10-day course is essential to achieve maximal pharyngeal eradication and prevent acute rheumatic fever—shortening the course by even a few days results in appreciable increases in treatment failure rates. 1, 2

• Amoxicillin is preferred over penicillin V in younger children due to better palatability and availability as suspension, although both have identical efficacy for Group A Streptococcus pharyngitis. 2
• The primary goal of treatment is preventing acute rheumatic fever and suppurative complications, not just symptom relief—antibiotics shorten symptom duration by only 1–2 days but are critical for preventing serious complications. 2

Why the Other Options Are Incorrect

Conservative Treatment (Option A) is Wrong

• Conservative management without antibiotics is inappropriate when Group A Streptococcus is confirmed, as the primary goal is preventing acute rheumatic fever, which requires bactericidal activity and adequate pharyngeal eradication. 1, 2
• While viral causes (adenovirus, enterovirus) account for the majority of exudative tonsillitis in children, Group A Streptococcus still requires treatment when documented. 3

5-Day Azithromycin (Option C) is Wrong

• Azithromycin should be reserved for patients with documented penicillin allergy who cannot tolerate first-line alternatives—it is not appropriate as first-line therapy. 2
• Macrolide resistance among Group A Streptococcus ranges from 5–8% in the United States, making it less reliable than amoxicillin. 2
• Azithromycin lacks data proving it prevents rheumatic fever, unlike penicillin/amoxicillin which have decades of evidence. 2
• While azithromycin requires only 5 days due to its prolonged tissue half-life, it should only be used when penicillin and preferred alternatives cannot be used. 2, 4

IM Penicillin (Option D) is Wrong

• Intramuscular benzathine penicillin G should be reserved for situations where compliance with oral therapy is questionable or impossible—not as routine first-line treatment. 5
• Oral amoxicillin is equally effective when compliance is assured and avoids the pain and inconvenience of injection. 1, 2

Critical Diagnostic Requirement Before Treatment

Group A Streptococcus infection must be confirmed with either a rapid antigen detection test or throat culture before prescribing antibiotics, as clinical features alone cannot reliably distinguish bacterial from viral pharyngitis in children. 2 The presence of tonsillar exudate increases the likelihood of Group A Streptococcus, but testing remains essential since 15–20% of asymptomatic children are colonized with Group A Streptococcus. 2

Specific Dosing Regimen

• Amoxicillin 40–50 mg/kg/day divided into two doses (maximum 1000 mg/dose) for 10 days is the recommended regimen. 2
• Alternative once-daily dosing of 840 mg (40 mg/kg) once daily is equally effective and may improve adherence. 2
• The full 10-day course is mandatory even if symptoms resolve in 3–4 days, as incomplete treatment dramatically increases treatment failure rates and rheumatic fever risk. 1, 2

Adjunctive Symptomatic Treatment

• Acetaminophen or ibuprofen should be offered for moderate to severe symptoms or high fever. 2
• Aspirin must be avoided in children due to Reye syndrome risk. 2

Common Pitfalls to Avoid

• Do not prescribe antibiotics empirically without confirming Group A Streptococcus—viral causes (especially adenovirus and enterovirus) account for nearly 50% of exudative tonsillitis in children and do not require antibiotics. 3
• Do not shorten the antibiotic course below 10 days based on clinical improvement—this increases treatment failure and rheumatic fever risk. 1, 2
• Do not use azithromycin or other macrolides as first-line therapy when amoxicillin can be used—reserve these for documented penicillin allergy. 2
• Do not assume all exudative tonsillitis requires antibiotics—Group A Streptococcus only contributed to 1% of cases in one pediatric study, with viruses being far more common. 3