What is the treatment for tonsillitis?

Treatment for Tonsillitis

Penicillin or amoxicillin remains the first-line treatment for bacterial tonsillitis caused by Group A Streptococcus, with a full 10-day course recommended to prevent complications such as rheumatic fever. 1

Diagnosis of Tonsillitis

Clinical Assessment

• Tonsillitis presents with sore throat, difficulty swallowing, and evidence of inflammation of the tonsils including erythema, edema, with or without exudate 2
• Fever may or may not be present 2
• Use Centor Criteria to guide testing and treatment decisions:
  • Tonsillar exudates
  • Tender anterior cervical lymph nodes
  • Lack of cough
  • Fever 1

Testing

• Obtain throat culture or rapid antigen detection test (RADT) before initiating antibiotics 2, 1
• Patients with 0-2 Centor criteria are unlikely to have Group A Streptococcal infection and don't require testing
• Those with 3-4 criteria should be tested with RADT and/or throat culture 1
• If using rapid diagnostic tests, findings must be confirmed by culture 2

Treatment Approach

Antimicrobial Therapy for Bacterial Tonsillitis

For confirmed Group A Streptococcal tonsillitis:

1. First-line options:

   • Penicillin V: 500 mg twice daily or 250 mg three times daily for 10 days in adults; 250 mg twice daily or 20 mg/kg/day divided every 8 hours for 10 days in children 1
   • Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) for 10 days 1

2. For penicillin-allergic patients:

   • Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
   • Clindamycin or clarithromycin 1
   • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 3

Symptomatic Treatment

• NSAIDs (ibuprofen) or acetaminophen for pain and fever management 1, 4
• Warm salt water gargles and throat lozenges to alleviate symptoms 1
• Dexamethasone may help reduce inflammation 4
• Adequate hydration is essential 5

Management of Recurrent Tonsillitis

Watchful Waiting

• Strong recommendation for watchful waiting 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 2

Surgical Intervention

• Tonsillectomy may be considered (option) for recurrent throat infection with:
  • ≥7 episodes in the past year, OR
  • ≥5 episodes per year for 2 years, OR
  • ≥3 episodes per year for 3 years 2, 1
• Each episode should be documented with: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive test for Group A Streptococcus 2

Treatment of Repeated Episodes

For patients with multiple repeated episodes of culture-positive acute pharyngitis:

• Consider intramuscular benzathine penicillin G if compliance with oral antibiotics is an issue 2
• Simultaneous cultures for all family contacts may be helpful if "ping-pong" spread is suspected 2

Important Considerations

Prevention of Complications

• Complete the full antibiotic course (10 days for penicillin/amoxicillin, 5 days for azithromycin) to prevent:
  • Acute rheumatic fever
  • Glomerulonephritis
  • Suppurative complications 1, 4

Viral vs. Bacterial Tonsillitis

• 70-95% of tonsillitis cases are viral in origin and require only supportive care 6, 5
• Bacterial infections (primarily Group A Streptococcus) account for 5-15% of cases in adults and 15-30% in children aged 5-15 years 6

Common Pitfalls

• Treating asymptomatic carriers - 10% of healthy children carry Streptococcus pyogenes without clinical signs; decolonization is not necessary 4, 7
• Unnecessary microbiological screening tests in asymptomatic children do not justify antibiotic treatment 4
• Relying solely on clinical presentation to differentiate viral from bacterial causes can lead to overtreatment 4
• Incomplete antibiotic courses may lead to treatment failure (up to 30%) 1

By following these evidence-based guidelines, clinicians can effectively manage tonsillitis while minimizing unnecessary antibiotic use and preventing serious complications.