What is the appropriate treatment for tonsillitis?

Treatment of Tonsillitis

For confirmed Group A Streptococcal (GAS) tonsillitis, treat with penicillin V or amoxicillin for 10 days; for viral tonsillitis (the majority of cases), provide supportive care only with analgesia and hydration. 1, 2

Diagnostic Approach: Determine If Antibiotics Are Needed

The critical first step is distinguishing bacterial from viral tonsillitis, as most cases are viral and do not require antibiotics 2. Use a clinical scoring system to estimate the probability of GAS infection:

• Apply the Centor or McIsaac score to assess likelihood of bacterial etiology 3, 4
• If score ≥3: Perform a rapid antigen detection test (RADT) for GAS 4
• If RADT is negative but clinical suspicion remains high: Obtain throat culture 4
• Do NOT prescribe antibiotics for low-risk patients (score <3 without positive testing) 4

Important caveat: Exudative tonsillitis in children is NOT automatically streptococcal—viral causes commonly produce exudate 4. Avoid the common pitfall of prescribing antibiotics based on appearance alone.

Antibiotic Treatment (Only for Confirmed GAS)

First-Line Therapy (No Penicillin Allergy)

Penicillin V (oral) 1:

• Children: 250 mg twice or three times daily for 10 days
• Adolescents/Adults: 250 mg four times daily OR 500 mg twice daily for 10 days
• Strength of recommendation: Strong, high quality evidence

Amoxicillin (oral) - equally effective alternative 1:

• 50 mg/kg once daily (max 1000 mg) for 10 days
• OR 25 mg/kg twice daily (max 500 mg per dose) for 10 days
• Strength of recommendation: Strong, high quality evidence

Benzathine penicillin G (intramuscular) - consider when adherence is a concern 1:

• <27 kg: 600,000 units (single dose)
• ≥27 kg: 1,200,000 units (single dose)

Penicillin Allergy Options

Cephalexin (avoid in immediate-type hypersensitivity) 1:

• 20 mg/kg/dose twice daily (max 500 mg/dose) for 10 days
• Strength: Strong, high quality

Clindamycin 1:

• 7 mg/kg/dose three times daily (max 300 mg/dose) for 10 days
• Strength: Strong, moderate quality

Azithromycin 1:

• 12 mg/kg once daily (max 500 mg) for 5 days
• Critical caveat: GAS resistance to macrolides varies geographically and temporally—not first-line 1, 4

The 10-day duration is essential to prevent acute rheumatic fever, reduce suppurative complications (peritonsillar abscess, cervical lymphadenitis, mastoiditis), and decrease transmission 1.

Supportive Care (All Patients)

• Analgesia: Combination of acetaminophen and/or NSAIDs 1, 2
• Hydration 2
• Topical agents (lozenges with benzocaine, lidocaine, or ambroxol) may provide temporary relief 1, 4
• Warm salt water gargles for patients able to gargle 1

Do NOT use corticosteroids routinely—despite some symptom relief, the self-limited nature of the disease, efficacy of analgesics, and potential adverse effects make steroids inappropriate 1.

Special Situations

Recurrent Tonsillitis

If a patient has multiple episodes shortly after treatment, consider three possibilities 1:

1. Non-adherence to antibiotics
2. New GAS infection from contacts
3. Chronic GAS carrier with intercurrent viral infections (most common)

GAS carriers do NOT require treatment in most cases—they are unlikely to spread infection or develop complications 1. Only treat carriers in special circumstances: community outbreaks of rheumatic fever, family history of rheumatic fever, or excessive family anxiety 1.

Tonsillectomy Indications

Tonsillectomy is indicated ONLY if the patient has 3:

• ≥7 adequately treated episodes in the preceding year, OR
• ≥5 episodes in each of the preceding 2 years, OR
• ≥3 episodes in each of the preceding 3 years

Do NOT perform tonsillectomy solely to reduce GAS pharyngitis frequency outside these criteria 1. The guideline evidence for this is strong and high quality.

Key Clinical Pitfalls to Avoid

1. Overprescribing antibiotics: Most tonsillitis is viral—use scoring systems and testing 2, 4
2. Wrong antibiotic choice: Penicillin/amoxicillin remain first-line; macrolides are NOT first-line due to resistance 1, 4
3. Inadequate duration: Must complete 10 days to prevent rheumatic fever 1
4. Treating carriers: Repeated positive tests with viral symptoms likely represent carriage—do not treat 1
5. Premature tonsillectomy: Surgery is only for severe recurrent cases meeting specific criteria 3, 5