What is the treatment for tonsillitis?

From the Guidelines

The treatment for tonsillitis should prioritize symptom relief for viral cases and antibiotics for bacterial cases, with consideration for tonsillectomy in severe or recurrent cases, as recommended by the most recent clinical practice guidelines 1.

Treatment Approach

For viral tonsillitis, which is the most common form, treatment focuses on symptom relief with:

• Rest
• Adequate hydration
• Warm salt water gargles
• Over-the-counter pain relievers like acetaminophen (325-650mg every 4-6 hours) or ibuprofen (400-600mg every 6-8 hours)

Bacterial Tonsillitis Treatment

For bacterial tonsillitis, particularly strep throat, antibiotics are necessary. First-line treatments include:

• Penicillin V (500mg twice daily for 10 days for adults)
• Amoxicillin (500mg twice daily for 10 days) For penicillin-allergic patients, alternatives include:
• Clindamycin (300mg three times daily for 10 days)
• Macrolides like azithromycin (500mg on day 1, then 250mg daily for 4 more days)

Tonsillectomy Consideration

Severe cases with recurrent infections or complications may require tonsillectomy, as suggested by the clinical practice guideline 1, which recommends tonsillectomy for recurrent throat infection with a frequency of 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.

Postoperative Care

For patients undergoing tonsillectomy, ibuprofen, acetaminophen, or both are recommended for pain control after tonsillectomy 1, based on systematic review and randomized controlled trials with a preponderance of benefit over harm.

Key Considerations

• Completing the full antibiotic course is crucial, even if symptoms improve, to prevent complications like rheumatic fever and kidney inflammation.
• Antibiotics are important for bacterial cases to reduce symptom duration and contagiousness.
• The decision to recommend tonsillectomy should be based on the frequency and severity of recurrent throat infections, as well as the presence of complications, in accordance with the latest clinical practice guidelines 1.

From the FDA Drug Label

Pharyngitis/tonsillitis caused by Streptococcus pyogenes as an alternative to first-line therapy in individuals who cannot use first-line therapy. NOTE: Penicillin by the intramuscular route is the usual drug of choice in the treatment of Streptococcus pyogenes infection and the prophylaxis of rheumatic fever. Azithromycin is often effective in the eradication of susceptible strains of Streptococcus pyogenes from the nasopharynx Because some strains are resistant to azithromycin, susceptibility tests should be performed when patients are treated with azithromycin.

The treatment for tonsillitis caused by Streptococcus pyogenes is usually penicillin by the intramuscular route, but azithromycin can be used as an alternative in individuals who cannot use first-line therapy.

• Azithromycin is often effective in eradicating susceptible strains of Streptococcus pyogenes from the nasopharynx.
• Susceptibility tests should be performed when patients are treated with azithromycin because some strains are resistant to it 2 2.

From the Research

Treatment for Tonsillitis

• The treatment for tonsillitis typically involves a combination of medications and surgical options, depending on the severity and frequency of the condition 3.
• For acute tonsillitis, treatment may include steroids, NSAIDs, and betalactam antibiotics, such as penicillin or cefuroxime 3.
• In some cases, a short-term course of late-generation antibiotics, such as azithromycin or clarithromycin, may be comparable to a longer course of penicillin therapy 3, 4, 5.
• However, it's worth noting that penicillin therapy for 10 days has been shown to be effective in preventing rheumatic fever and glomerulonephritic diseases 3, 4.

Surgical Options

• Tonsillectomy, or the removal of the tonsils, may be considered in cases of recurrent acute bacterially tonsillitis, especially in children under six years old 3.
• Partial tonsillectomy, also known as tonsillotomy, may be a preferred option for some patients, as it has a lower risk of postoperative pain and hemorrhage 3.
• The decision to undergo tonsillectomy should be made on a case-by-case basis, taking into account the frequency and severity of the condition, as well as the patient's overall health and medical history 3, 6.

Antibiotic Treatment

• The choice of antibiotic treatment for tonsillitis may depend on various factors, including the severity of the condition, the patient's medical history, and the presence of any underlying health conditions 4, 7, 6, 5.
• Clindamycin and amoxicillin with clavulanate have been shown to be effective in preventing future attacks of acute pharyngo-tonsillitis and eradicating group A streptococci from the tonsils 6.
• Azithromycin has also been shown to be effective in the treatment of acute streptococcal pharyngitis/tonsillitis in pediatric patients, with a satisfactory clinical response and bacteriological eradication rates comparable to penicillin V 5.