What is the initial management of tonsillitis in a hospital setting?

Initial Management of Tonsillitis in a Hospital Setting

The initial management of tonsillitis in a hospital setting should focus on supportive care, accurate diagnosis, and appropriate antimicrobial therapy when indicated by bacterial etiology, with watchful waiting recommended for most cases of recurrent tonsillitis that don't meet specific frequency criteria.

Diagnostic Approach

Clinical Assessment

• Evaluate for key clinical features:
  • Temperature >38.3°C (101°F)
  • Cervical adenopathy
  • Tonsillar exudate
  • Absence of cough 1
• Apply Centor score to estimate probability of Group A Streptococcal (GAS) infection:
  • 4 criteria present: 56% risk of GAS
  • 3 criteria present: 32% risk of GAS
  • 1 criterion present: 6.5% risk of GAS
  • 0 criteria present: 2.5% risk of GAS 1

Laboratory Testing

• Throat swab for rapid antigen detection test (RADT) and/or culture when bacterial etiology is suspected
• Document each episode thoroughly in medical record, including:
  • Symptoms
  • Physical findings
  • Test results
  • Days of school/work absence
  • Quality of life impact 1

Initial Treatment

Supportive Care (First-Line)

• Adequate hydration
• Analgesics:
  • Acetaminophen and/or NSAIDs for pain and fever control 1
  • Topical agents (rinses, sprays, lozenges) may provide temporary symptomatic relief 1
  • Warm salt water gargles for patients old enough to gargle 1

Antimicrobial Therapy

• For confirmed or highly suspected GAS tonsillitis:
  • First-line: Penicillin V (remains treatment of choice) 1, 2
  • Alternative for penicillin allergy: Azithromycin (12 mg/kg once daily for 5 days) 2
  • Clinical success rates with azithromycin: 98% at day 14 and 94% at day 30 2

Management of Recurrent Tonsillitis

Watchful Waiting Criteria

• Strongly recommend watchful waiting for recurrent throat infection if there have been:
  • <7 episodes in the past year
  • <5 episodes per year in the past 2 years
  • <3 episodes per year in the past 3 years 1

Tonsillectomy Consideration Criteria

• May recommend tonsillectomy if frequency criteria are met:
  • ≥7 documented episodes in the past year, OR
  • ≥5 documented episodes per year for 2 years, OR
  • ≥3 documented episodes per year for 3 years 1
• Each episode must be documented with at least one of:
  • Temperature >38.3°C
  • Cervical adenopathy
  • Tonsillar exudate
  • Positive test for GAS 1

Modifying Factors for Tonsillectomy

• Consider tonsillectomy even if frequency criteria not met in presence of:
  • Multiple antibiotic allergies/intolerance
  • PFAPA (periodic fever, aphthous stomatitis, pharyngitis, adenitis)
  • History of >1 peritonsillar abscess 1

Special Considerations

Complications to Monitor

• Peritonsillar abscess
• Parapharyngeal abscess
• Acute rheumatic fever
• Acute glomerulonephritis 1, 3

Chronic Carriers

• GAS carriers generally do not require antimicrobial therapy as they:
  • Are unlikely to spread GAS pharyngitis to close contacts
  • Have little to no risk for developing suppurative or nonsuppurative complications 1

Common Pitfalls to Avoid

1. Overuse of antibiotics: Most cases (70-95%) of tonsillitis are viral in origin and do not require antibiotics 3

2. Inadequate documentation: Thorough documentation of each episode is crucial for appropriate management decisions and potential surgical consideration 1

3. Premature consideration of tonsillectomy: Benefits of tonsillectomy are modest, with only modest reduction in throat infections in the first year, and benefits diminishing in subsequent years 4

4. Failure to distinguish carriers from active infection: Chronic GAS carriers experiencing viral pharyngitis may be misdiagnosed as having recurrent GAS tonsillitis 1

5. Overlooking modifying factors: Some patients may benefit from tonsillectomy even if they don't meet standard frequency criteria due to specific modifying factors 1