What is the recommended management—including rapid antigen detection testing, antibiotic selection and dosing (penicillin V, amoxicillin, macrolides, clindamycin, cefdinir, cefuroxime), allergy alternatives, symptomatic care, and criteria for tonsillectomy—for a child with suspected bacterial tonsillitis?

Treatment of Tonsillitis in Children

For suspected bacterial tonsillitis in children, obtain rapid antigen detection testing (RADT) or throat culture before prescribing antibiotics, then treat confirmed Group A Streptococcus (GAS) with penicillin V or amoxicillin for 10 days, provide ibuprofen or acetaminophen for pain control, and consider tonsillectomy only if the child meets strict Paradise criteria (≥7 documented episodes in 1 year, or ≥5 per year for 2 years, or ≥3 per year for 3 years). 1, 2

Diagnostic Testing

Microbiological confirmation is mandatory before antibiotic therapy:

• Obtain a throat swab contacting both sides of the posterior pharynx and uvula; culture on sheep's blood agar to identify GAS by bacitracin method or equivalent 2
• If RADT is negative in a child, confirm with throat culture; cultures negative at 24 hours should be reincubated for an additional 24 hours to improve detection sensitivity 2
• Document fever ≥38.3°C (101°F), anterior cervical lymphadenopathy, tonsillar exudate, and test results for every episode 2
• Do not prescribe antibiotics for RADT/culture-negative cases—these are viral infections requiring only supportive care 2, 3

Antibiotic Selection and Dosing

First-Line Therapy (No Penicillin Allergy)

• Penicillin V oral: Children 250 mg twice or three times daily; adolescents/adults 250 mg four times daily or 500 mg twice daily for 10 days 1
• Amoxicillin oral: 50 mg/kg once daily (max 1000 mg) or 25 mg/kg twice daily (max 500 mg per dose) for 10 days 1
• Benzathine penicillin G intramuscular: <27 kg: 600,000 units; ≥27 kg: 1,200,000 units as a single dose 1

Penicillin Allergy Alternatives

For non-anaphylactic penicillin allergy (avoid in immediate-type hypersensitivity):

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

For anaphylactic penicillin allergy:

• Clindamycin oral: 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days 1
• Azithromycin oral: 12 mg/kg once daily (max 500 mg) for 5 days (note: GAS resistance varies geographically and temporally) 1
• Clarithromycin oral: 7.5 mg/kg/dose twice daily (max 250 mg/dose) for 10 days (note: resistance concerns apply) 1

Critical Antibiotic Pitfall

The 10-day duration is essential for preventing rheumatic fever and glomerulonephritis—shorter courses may relieve symptoms but do not provide this protection. 1, 4

Symptomatic Care

• Provide ibuprofen, acetaminophen, or combination therapy for pain control 2
• Never prescribe codeine-containing medications to children younger than 12 years—this is explicitly contraindicated 2

Documentation Requirements

Meticulous documentation is essential for future surgical decision-making:

• Record temperature, cervical adenopathy, exudate findings, RADT/culture results, and school-absence days for each episode 2
• Only 17% of patients with frequent infections have sufficient documentation to assess surgical eligibility 2

Tonsillectomy Criteria

Watchful Waiting (Observation Preferred)

Recommend observation rather than surgery when:

• Fewer than 7 episodes in the past year, or
• Fewer than 5 episodes per year over the past 2 years, or
• Fewer than 3 episodes per year over the past 3 years 2

Paradise Criteria for Surgical Consideration

Consider tonsillectomy only if ALL of the following are met:

• Frequency: ≥7 documented episodes in the past year OR ≥5 episodes per year for 2 years OR ≥3 episodes per year for 3 years 2
• Each episode documented with: fever >38.3°C, cervical adenopathy, tonsillar exudate, OR positive GAS test 2
• Antibiotics administered for proven or suspected streptococcal episodes 2
• Contemporaneous notation in the medical record 2

Modifying Factors Favoring Earlier Surgery

These factors may justify tonsillectomy before meeting full Paradise criteria:

• Multiple antibiotic allergies or intolerance 2
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis) 2
• History of >1 peritonsillar abscess 2
• Recurrent severe infections requiring hospitalization 2
• Complications such as Lemierre syndrome 2

Expected Surgical Outcomes

Tonsillectomy provides modest short-term benefit only:

• Reduces throat infection frequency for the first postoperative year only; benefits do not extend beyond that period 2
• In randomized trials, children meeting Paradise criteria who were observed without surgery experienced an average of 1.17 infection episodes in the following year, indicating high rates of spontaneous improvement 2

Special Consideration: GAS Carriers

Distinguish carriers from active infection:

• Carriers harbor GAS without active infection and test positive during viral illnesses 3
• Do not treat carriers routinely—they are unlikely to spread GAS or develop complications 1
• Consider carrier eradication only during community outbreaks of rheumatic fever, glomerulonephritis, or invasive GAS infection, or in patients with personal/family history of rheumatic fever 3
• Carrier eradication regimen (when indicated): Clindamycin 20-30 mg/kg/day in three divided doses (max 300 mg per dose) for 10 days 3

Common Pitfalls to Avoid

• Prescribing antibiotics based solely on exudates without microbiological confirmation—many viral infections cause exudative tonsillitis 2, 5
• Using white blood cell count or C-reactive protein to justify antibiotics—these do not reliably distinguish bacterial from viral infection 5
• Failing to document infection episodes adequately, which impairs future surgical eligibility assessments 2
• Recommending tonsillectomy without satisfying Paradise criteria or without a 12-month observation period 2
• Treating positive GAS tests in asymptomatic carriers or those with viral symptoms (cough, rhinorrhea, hoarseness) 3