What is the appropriate treatment for acute suppurative tonsillitis?

Treatment of Acute Suppurative Tonsillitis

For confirmed bacterial acute suppurative tonsillitis, prescribe penicillin V or amoxicillin for a full 10-day course to prevent suppurative complications and acute rheumatic fever. 1, 2

Confirm Bacterial Etiology Before Treatment

• Perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) before initiating antibiotics—do not prescribe based on clinical appearance alone. 3, 2, 4
• Bacterial tonsillitis presents with sudden onset sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 3, 4
• Viral tonsillitis (which does not require antibiotics) typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy. 3, 4

First-Line Antibiotic Regimens (Non-Penicillin Allergic)

Penicillin V (preferred): 1, 2

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

Amoxicillin (equally effective alternative): 1, 2, 5

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

Benzathine penicillin G (intramuscular, single dose option): 1

• <27 kg: 600,000 units IM once
• ≥27 kg: 1,200,000 units IM once

Alternative Regimens for Penicillin Allergy

For non-anaphylactic penicillin allergy (first-generation cephalosporins): 1, 2

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

For anaphylactic penicillin allergy: 1, 2

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

Critical Duration Requirements

• The full 10-day course is mandatory for penicillins, cephalosporins, clindamycin, and clarithromycin to maximize bacterial eradication and prevent acute rheumatic fever. 1, 2, 5
• Azithromycin requires only 5 days due to its prolonged tissue half-life. 1, 2
• Short courses (5 days) of standard-dose penicillin are less effective for GAS eradication and should be avoided. 1, 3
• Note that macrolide resistance varies geographically and temporally—consider local resistance patterns. 1

Adjunctive Symptomatic Management

• Provide NSAIDs (ibuprofen) or acetaminophen for pain and fever control in all patients regardless of antibiotic use. 1, 2, 4
• Avoid aspirin in children due to Reye's syndrome risk. 2
• Encourage adequate hydration and rest. 4
• Warm salt water gargles may provide symptomatic relief in patients old enough to perform them. 3

Management of Treatment Failure or Recurrent Episodes

If symptoms return within 2 weeks of completing standard therapy: 3

• Clindamycin: 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days

• Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses (maximum 2000 mg amoxicillin/day) for 10 days

• Penicillin V with rifampin: Penicillin V 50 mg/kg/day in 4 doses for 10 days plus rifampin 20 mg/kg/day in 1 dose for the last 4 days

• Consider that the patient may be a chronic GAS carrier experiencing intercurrent viral infections rather than recurrent bacterial tonsillitis. 3

• Chronic carriers are unlikely to spread GAS and are at very low risk for complications—they do not require treatment. 1, 3

Key Clinical Pitfalls to Avoid

• Never prescribe antibiotics without confirming bacterial infection through RADT or throat culture—viral tonsillitis does not benefit from antibiotics and inappropriate use contributes to antimicrobial resistance. 3, 2, 4
• Do not use antibiotic courses shorter than 10 days for confirmed GAS (except azithromycin 5 days)—this increases treatment failure risk and does not prevent rheumatic fever. 1, 3, 2
• Avoid broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS. 2, 4
• Do not perform follow-up throat cultures for asymptomatic patients who have completed appropriate antibiotic therapy. 3
• Tonsillectomy is not recommended solely to reduce the frequency of GAS pharyngitis. 1, 3