What is the treatment for tonsillitis?

From the Guidelines

Tonsillitis treatment should prioritize symptom management for viral cases and antibiotics for bacterial cases, with consideration for tonsillectomy in severe or recurrent cases, as supported by the most recent guidelines 1.

Treatment Approach

The approach to treating tonsillitis depends on its cause, with viral tonsillitis managed through symptom relief and bacterial tonsillitis requiring antibiotic therapy. For viral tonsillitis, treatment includes rest, hydration, warm salt water gargles, and over-the-counter pain relievers like acetaminophen or ibuprofen. Bacterial tonsillitis, particularly strep throat, is treated with antibiotics such as penicillin V or amoxicillin, with alternatives for penicillin-allergic patients including clindamycin or azithromycin.

Antibiotic Treatment

• Penicillin V: 500mg twice daily for 10 days for adults.
• Amoxicillin: 500mg twice daily for 10 days.
• Clindamycin: 300mg three times daily for 10 days, for penicillin-allergic patients.
• Azithromycin: 500mg on day 1, then 250mg daily for 4 more days, for penicillin-allergic patients.

Consideration for Tonsillectomy

Tonsillectomy may be considered for recurrent throat infections, defined as at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, with documentation of sore throat and at least one of the following: temperature > 38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus, as recommended by recent clinical practice guidelines 1.

Quality of Life and Morbidity Considerations

The decision to proceed with tonsillectomy should also consider the potential impact on quality of life and morbidity, with evidence suggesting modest improvement in severely and frequently affected children, along with notable improvement in quality of life 1. It's essential to weigh the benefits against the harms and involve patients and their families in shared decision-making, as emphasized in recent guidelines 1.

From the FDA Drug Label

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)

Pharyngitis/Tonsillitis (dosage regimen: 12 mg/kg on Days 1 to 5) Safety and effectiveness in the treatment of pediatric patients with pharyngitis/tonsillitis under 2 years of age have not been established.

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) for patients with pharyngitis due to documented Group A β-hemolytic streptococci.

• Key points:
  • Azithromycin is effective for the treatment of pharyngitis/tonsillitis.
  • The recommended dosage of azithromycin is 12 mg/kg once a day for 5 days.
  • Penicillin V is also effective, with a recommended dosage of 250 mg three times a day for 10 days.
  • Safety and effectiveness in pediatric patients under 2 years of age have not been established 2.
• Note: Erythromycin is also used to treat streptococcal infections of the upper respiratory tract, including tonsillitis, with a therapeutic dosage administered for at least ten days 3.

From the Research

Treatment Options for Tonsillitis

• The primary objective of antibiotic therapy for tonsillitis caused by Group A beta-hemolytic streptococcal (GABHS) infections is to prevent rheumatic fever, reduce contagion, and achieve faster clinical improvement 4.
• Penicillin is currently recommended as the first-line therapy for GABHS infections, with erythromycin recommended for patients allergic to penicillin 4.
• However, penicillin treatment failures can occur, with rates ranging from 5% to 35% of patients not experiencing bacteriologic eradication 4, 5.
• Alternative antibiotics, such as cephalosporins, azithromycin, and clindamycin, have been shown to be effective in eradicating GABHS infections, especially in patients who have failed previous penicillin therapy 5, 6, 7.
• The use of rapid antigen detection tests, such as RAD, can help identify patients with acute streptococcal pharyngo-tonsillitis who require antibiotic therapy, reducing unnecessary antibiotic use and promoting more targeted treatment 8.

Antibiotic Therapy Duration

• The recommended duration of penicillin therapy for GABHS infections is 10 days to optimize cure 4.
• However, shorter courses of antibiotics, such as 5-day regimens of cefpodoxime or azithromycin, have been approved by the US Food and Drug Administration and may be effective in selected patients 4, 6.

Management of Penicillin Treatment Failure

• Patients who fail penicillin therapy may require alternative antibiotics, such as cephalosporins or macrolides, to eradicate the infection 5, 7.
• Treatment of tonsillitis in patients who failed penicillin therapy should aim to eradicate beta-lactamase-producing bacteria (BLPB) that protect GABHS from penicillin, while preserving the oropharyngeal "protective" organisms 7.