What is the treatment for tonsillitis?

Treatment of Tonsillitis

The first-line treatment for bacterial tonsillitis is penicillin or amoxicillin for a full 10-day course to prevent complications such as acute rheumatic fever. 1

Diagnosis and Assessment

• Use the Centor Criteria to guide testing and treatment decisions:

  1. Tonsillar exudates
  2. Tender anterior cervical lymph nodes
  3. Lack of cough
  4. Fever 1

• Patients with 0-2 Centor criteria are unlikely to have Group A Streptococcal (GAS) infection and don't require testing

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

• Clinical features alone cannot reliably differentiate bacterial from viral tonsillitis, making laboratory confirmation necessary 1, 2

Treatment Algorithm

1. Bacterial Tonsillitis (Confirmed or Highly Suspected)

First-line Antibiotics:

• Adults: Penicillin V 500 mg 2-3 times daily for 10 days OR amoxicillin 500 mg twice daily or 1000 mg once daily for 10 days 1
• Children: Penicillin V 250 mg 2-3 times daily OR amoxicillin 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1

For Penicillin Allergy:

• Non-anaphylactic allergy: First-generation cephalosporins for 10 days
• Anaphylactic allergy: Clindamycin (300-450 mg orally three times daily for 10 days), clarithromycin, or azithromycin (12 mg/kg once daily, max 500 mg, for 5 days) 1, 3

For Treatment Failures:

• Consider clindamycin, amoxicillin-clavulanate, or cephalosporins 1

2. Viral Tonsillitis

• Supportive care with analgesics/antipyretics and hydration 1, 2
• No antibiotics required

Symptomatic Relief (For Both Bacterial and Viral Tonsillitis)

• Acetaminophen or NSAIDs (ibuprofen) for pain and fever relief 1, 4
• Avoid aspirin in children due to risk of Reye syndrome 1
• Throat lozenges and warm salt water gargles 1
• Cold liquids or ice chips to soothe throat 1
• Avoid hot liquids, spicy foods, and hard foods that may irritate the throat 1

Prevention and Infection Control

• Patients should complete at least 24 hours of antibiotics before returning to school or work 1
• Implement proper hand hygiene and other infection control measures 1

Special Considerations

Recurrent Tonsillitis

• Tonsillectomy may be considered for patients with recurrent streptococcal pharyngitis 1, 4
• Partial tonsillectomy (tonsillotomy) should be considered for children under six years with tonsil hyperplasia rather than recurrent infections 4

Complications to Monitor

• Peritonsillar abscess
• Acute rheumatic fever
• Retropharyngeal abscess 2

Important Caveats

• A full 10-day course of beta-lactam antibiotics is mandatory to prevent acute rheumatic fever 1
• Azithromycin is effective with a shorter 5-day course but has increasing resistance in some regions 1, 5
• If symptoms persist after 48-72 hours of antibiotic therapy, reevaluation is necessary 1
• Corticosteroids are not routinely recommended for tonsillitis 1

Remember that while short-course antibiotics may clear streptococci from the throat, the 10-day course is specifically designed to prevent serious complications like rheumatic fever 1, 6.