Treatment of Recurrent Tonsillitis

Immediate Management Approach

• The Infectious Diseases Society of America recommends treating recurrent tonsillitis that has failed both azithromycin and amoxicillin-clavulanate with clindamycin 20-30 mg/kg/day divided into 3 doses for 10 days (or 600 mg/day in adults divided into 2-4 doses) 1, 2
• True recurrent Group A Streptococcal (GAS) pharyngitis is characterized by multiple bona fide infections requiring aggressive treatment, whereas chronic GAS carrier with viral infections is a patient colonized with GAS who experiences intercurrent viral pharyngitis that tests positive for GAS but doesn't represent true bacterial infection 2
• Carriers lack rising anti-streptococcal antibody titers and have no active immunologic response, and are at very low risk for complications and unlikely to spread infection to contacts 2
• If the patient is a carrier, antimicrobial therapy is not indicated 2
• The IDSA guidelines provide options for recurrent/treatment-failure cases, including clindamycin as the first choice, with a recommended regimen of 20-30 mg/kg/day divided into 3 doses for 10 days (max 300 mg/dose) for children, and 600 mg/day divided into 2-4 doses for 10 days for adults, with an evidence rating of Strong, high quality 1, 2, 3

When to Consider Tonsillectomy

• Tonsillectomy should be considered if the patient meets Paradise criteria, which include ≥7 episodes in the past year, OR ≥5 episodes per year for 2 consecutive years, OR ≥3 episodes per year for 3 consecutive years, with each episode documented with specific symptoms and positive test for Group A beta-hemolytic streptococcus 4, 5
• The American Academy of Otolaryngology-Head and Neck Surgery states that tonsillectomy is "an option" for children meeting Paradise criteria, while the Infectious Diseases Society of America does not recommend tonsillectomy solely to reduce the frequency of GAS pharyngitis (strong recommendation, high-quality evidence) 2, 4

Clinical Pitfalls to Avoid

• The Infectious Diseases Society of America recommends against routinely testing or treating asymptomatic contacts, and against using long-term antibiotic prophylaxis except for patients with history of rheumatic fever 1, 3
• The Infectious Diseases Society of America also recommends against performing routine post-treatment cultures, and against assuming all positive tests mean active infection, considering carrier state especially if episodes are frequent and close together 1, 2, 3