What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

For tonsillitis caused by Group A Streptococcus (GAS), a 10-day course of penicillin remains the standard treatment, though shorter courses of certain antibiotics may be appropriate in specific circumstances. 1

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Clinical assessment: Look for fever, anterior cervical adenitis, tonsillopharyngeal exudates, and absence of cough
• Testing: Rapid antigen detection test (RADT) and/or throat culture for GAS
• Important: Only treat with antibiotics if GAS is confirmed 1

Treatment Algorithm

1. Viral Tonsillitis (70-95% of cases) 2

• Supportive care only:
  • Analgesics (acetaminophen, NSAIDs)
  • Adequate hydration
  • Salt water gargles
  • Throat lozenges (for patients old enough to use safely)

2. Bacterial Tonsillitis (Confirmed GAS)

First-line treatment:

• Penicillin V:
  • Children: Weight-based dosing for 10 days
  • Adults: 500 mg twice daily for 10 days 1

Alternative regimens (penicillin allergy or treatment failure):

• Clindamycin:

  • Children: 20-30 mg/kg/day in 3 divided doses for 10 days
  • Adults: 600 mg/day in 2-4 divided doses for 10 days 1

• Amoxicillin-clavulanic acid:

  • Children: 40 mg/kg/day in 3 divided doses for 10 days
  • Adults: 500 mg twice daily for 10 days 1

• Azithromycin (for penicillin allergy):

  • 12 mg/kg once daily for 5 days (children)
  • Note: Clinical success rates of 94-98% have been demonstrated 3

Duration Considerations

While 10-day courses remain standard, evidence suggests:

• Standard-dose penicillin should generally be given for 10 days to ensure bacterial eradication and prevent complications 1
• High-dose penicillin given four times daily for 5 days may be an alternative in adults 1
• Oral cephalosporins may be effective in shorter courses with better microbial eradication than penicillin 1

Management of Recurrent Tonsillitis

For patients with multiple recurrent episodes of GAS tonsillitis:

1. Antimicrobial options:

   • Clindamycin
   • Amoxicillin-clavulanic acid
   • Benzathine penicillin G (with or without rifampin) 1

2. Consider tonsillectomy if:

   • ≥7 episodes in the past year, OR
   • ≥5 episodes per year for 2 consecutive years, OR
   • ≥3 episodes per year for 3 consecutive years (Paradise criteria) 1, 4

Special Considerations

• Tonsil stones (tonsilloliths): Conservative management with good oral hygiene and gentle removal; tonsillectomy rarely indicated unless causing significant symptoms 4
• Post-treatment: No follow-up cultures needed if symptoms resolve 1
• Family members: Routine testing of asymptomatic family contacts is not recommended 1

Common Pitfalls to Avoid

1. Treating without confirmation: Don't prescribe antibiotics without confirming GAS infection
2. Inadequate duration: Shortening standard penicillin therapy may lead to treatment failure and complications
3. Inappropriate use of macrolides: Due to increasing resistance, macrolides should not be first-line therapy 1
4. Overlooking complications: Monitor for peritonsillar abscess, rheumatic fever, and glomerulonephritis
5. Unnecessary tonsillectomy: Surgery should only be considered after meeting specific criteria for recurrence

By following these evidence-based recommendations, clinicians can effectively manage tonsillitis while minimizing antibiotic resistance and unnecessary interventions.