From the Guidelines
Treatment for tonsillitis typically involves managing symptoms and addressing the underlying cause, with supportive care and antibiotics as necessary, and tonsillectomy considered for recurrent or chronic cases. For viral tonsillitis, which is most common, treatment focuses on supportive care including:
- Rest
- Adequate hydration
- Warm salt water gargles
- Over-the-counter pain relievers such as acetaminophen (325-650mg every 4-6 hours, not exceeding 3000mg daily) or ibuprofen (400-600mg every 6-8 hours with food) 1. For bacterial tonsillitis, particularly strep throat, antibiotics are necessary.
- Penicillin V (500mg twice daily for 10 days for adults) is the first-line treatment, with amoxicillin (500mg three times daily for 10 days) as an alternative 1.
- For penicillin-allergic patients, clindamycin (300mg three times daily for 10 days) or azithromycin (500mg on day 1, then 250mg daily for 4 more days) may be prescribed 1. It's crucial to complete the full antibiotic course even if symptoms improve to prevent complications like rheumatic fever. For recurrent or chronic tonsillitis, tonsillectomy might be considered, especially if episodes occur more than 7 times in one year, 5 times per year for two consecutive years, or 3 times per year for three consecutive years 1. While recovering, soft foods, cold beverages, and throat lozenges can provide additional comfort. The most recent and highest quality study, a 2021 systematic review, recommends a multimodal approach to pain management after tonsillectomy, including the use of nonsteroidal anti-inflammatory drugs, acetaminophen, and opioids as needed, as well as the consideration of alternative therapies such as magnesium sulphate and sucralfate 1.
From the FDA Drug Label
Pharyngitis/Tonsillitis In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS): Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14Day 30 Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%) Penicillin V242/332 (73%)206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%) Penicillin V284/338 (84%)241/325 (74%)
The treatment for tonsillitis is azithromycin (12 mg/kg once a day for 5 days) or penicillin V (250 mg three times a day for 10 days), with azithromycin being clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 2.
- Key points:
- Azithromycin has a clinical success rate of 98% at Day 14 and 94% at Day 30.
- Penicillin V has a clinical success rate of 84% at Day 14 and 74% at Day 30.
- Azithromycin is clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30. The recommended dose of azithromycin for children with pharyngitis/tonsillitis is 12 mg/kg once daily for 5 days 2.
From the Research
Treatment for Tonsillitis
The treatment for tonsillitis depends on the cause of the infection.
- If the cause is viral, the treatment is supportive with analgesia and hydration 3.
- If the cause is bacterial, specifically group A beta-hemolytic streptococcus, the treatment is with antibiotics, typically penicillin as the first-line antibiotic 4, 5.
Antibiotic Treatment
- Oral penicillin is the first-line therapy for β-hemolytic streptococci 5.
- Alternative treatments with oral cephalosporins or macrolides can be used in cases of penicillin failure, frequent recurrences, or allergy/incompatibility of penicillin 5.
- A three-day course of azithromycin has been shown to be as effective and well-tolerated as a ten-day course of clarithromycin in adults with acute upper respiratory tract infections, including tonsillitis 6.
Recurrent Tonsillitis
- Watchful waiting is recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years 4.
- Tonsillectomy is indicated and highly effective if the patient has had ≥7 adequately treated episodes in the preceding year, ≥5 such episodes in each of the preceding 2 years, or ≥3 such episodes in each of the preceding 3 years 7.