What is the treatment for tonsillitis?

Treatment of Tonsillitis

The first-line treatment for bacterial tonsillitis is oral penicillin V or amoxicillin for 10 days, with azithromycin as an alternative for penicillin-allergic patients. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Use the Centor criteria to assess likelihood of bacterial infection 1:

  • Fever by history
  • Tonsillar exudates
  • Tender anterior cervical adenopathy
  • Absence of cough

• Patients with 0-2 Centor criteria likely have viral infection and don't require testing 1

• Patients with 3-4 Centor criteria should receive rapid antigen detection test (RADT) and/or throat culture 1

Treatment Algorithm

1. Bacterial Tonsillitis (Group A Streptococcus)

First-line antibiotics:

• Penicillin V: 250mg 2-3 times daily for children, 500mg 2-3 times daily for adolescents/adults for 10 days 1
• Amoxicillin: 50mg/kg once daily (maximum 1000mg) or 25mg/kg twice daily (maximum 500mg per dose) for 10 days 1

For penicillin-allergic patients:

• Azithromycin: 12mg/kg once daily (maximum 500mg) for 5 days 1, 2
• Cephalexin: 20mg/kg twice daily (maximum 500mg per dose) for 10 days (if no anaphylactic reaction to penicillin) 1
• Clindamycin: 7mg/kg three times daily (maximum 300mg per dose) for 10 days 1

2. Viral Tonsillitis

• Supportive care with symptomatic treatment 3, 4
• No antibiotics indicated

3. Symptomatic Treatment (for both viral and bacterial)

• NSAIDs (e.g., ibuprofen) - first-line for pain management 1, 4
• Acetaminophen for fever and pain relief 1
• Warm salt water gargles 1
• Throat lozenges for symptomatic relief 1
• Single intraoperative dose of dexamethasone if severe inflammation 5

Surgical Management Considerations

Tonsillectomy should be considered for recurrent tonsillitis based on the Paradise criteria 5, 4, 6:

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

For children under 6 years with tonsillar hyperplasia (not recurrent infection), partial tonsillectomy (tonsillotomy) is preferred due to lower risk of hemorrhage and pain 4.

Important Clinical Pearls

1. Complete the full antibiotic course even if symptoms improve quickly to prevent rheumatic fever and glomerulonephritis 1, 4

2. Patients are considered non-contagious after 24 hours of appropriate antibiotic therapy 1

3. Short-term antibiotic therapy (3-5 days with azithromycin) is comparable to long-term penicillin therapy for symptom reduction, but only the 10-day therapy has proven effective in preventing rheumatic fever 4

4. Penicillin failure rates have increased from 2-10% in the 1970s to approximately 30% currently, often due to poor compliance with the 10-day regimen 7

5. Routine post-treatment throat cultures are not recommended for asymptomatic individuals who have completed appropriate therapy 1

6. Advise patients to return if:

   • Symptoms persist beyond 7 days
   • Difficulty swallowing or breathing develops
   • High fever persists despite antipyretics
   • Purulent tonsillar exudates or tender cervical lymphadenopathy develops 1

By following this evidence-based approach to tonsillitis management, clinicians can effectively treat the condition while minimizing complications and antibiotic resistance.