What is the treatment for tonsillitis?

Treatment of Tonsillitis

Penicillin or amoxicillin are the first-line antibiotics for tonsillitis caused by Group A Streptococcus due to their proven efficacy in preventing rheumatic fever, narrow antimicrobial spectrum, low cost, and excellent safety profile. 1

Diagnosis and Assessment

Before initiating treatment, proper diagnosis is essential:

• Use the Centor Criteria to assess likelihood of streptococcal tonsillitis:

  • Tonsillar exudates
  • Tender anterior cervical lymph nodes
  • Lack of cough
  • Fever

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

• Patients with 0-2 Centor criteria are unlikely to have GAS infection and do not require testing 1

• Children under 3 years rarely need testing for GAS pharyngitis 1

Treatment Algorithm

First-Line Treatment for Bacterial Tonsillitis

1. Penicillin V or Amoxicillin:
   • Amoxicillin: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1
   • Standard oral therapy duration of 10 days is recommended to ensure eradication and prevent complications 1

For Penicillin-Allergic Patients

1. First-generation cephalosporins (if no history of anaphylaxis to penicillin):

   • Cephalexin is preferred over macrolides due to lower relapse rates 1

2. Clindamycin:

   • 300-450 mg orally three times daily for 10 days 1
   • Particularly effective for patients with multiple recurrent episodes

3. Macrolides (if unable to tolerate other options):

   • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 1
   • Erythromycin: 250 mg four times daily for 10 days 2

For Recurrent Infections

For patients with multiple repeated culture-positive episodes:

1. Clindamycin: 20-30 mg/kg/day for children or 600 mg/day in 2-4 divided doses for adults for 10 days 1
2. Amoxicillin/clavulanate: 40 mg/kg/day in 3 divided doses for 10 days 1
3. Benzathine penicillin G: Recommended for patients with questionable compliance 1

Management of Treatment Failure

If initial therapy fails:

1. Assess patient compliance with the prescribed regimen
2. Evaluate if the patient is a streptococcal carrier with concurrent viral infection
3. For patients who failed amoxicillin, switch to amoxicillin-clavulanate
4. Clindamycin is an effective option for continued treatment failure 1

Viral Tonsillitis Management

Since 70-95% of tonsillitis cases are viral in origin 3, supportive care is the mainstay of treatment:

• Analgesics/antipyretics: Acetaminophen or NSAIDs for moderate to severe symptoms or fever control
• Topical remedies: Warm salt water gargles, cold liquids, ice chips
• Hydration: Maintain adequate fluid intake 1
• Avoid aspirin in children due to risk of Reye syndrome 1

Prevention and Return to Normal Activities

• Patients with streptococcal tonsillitis are considered non-contagious after 24 hours of effective antibiotic therapy 1
• Children and adults may return to school or work after completing 24 hours of appropriate antibiotic therapy, provided they are feeling well enough and fever has resolved 1
• Preventive measures include hand hygiene, avoiding close contact with infected individuals, and not sharing utensils or drinks 1

Surgical Considerations

Tonsillectomy should be considered in cases of:

• Recurrent tonsillitis meeting Paradise criteria: 7+ episodes in the past year, 5+ episodes per year for two consecutive years, or 3+ episodes per year for three consecutive years 4
• Peritonsillar abscess
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) 4

For children under six years with tonsil hyperplasia without recurrent infections, partial tonsillectomy (tonsillotomy) is preferred due to lower risk of postoperative pain and hemorrhage 4.