Treatment of Follicular Tonsillitis
For follicular tonsillitis, penicillin remains the first-line antibiotic treatment, with azithromycin as an effective alternative for penicillin-allergic patients.
Diagnosis and Etiology
Follicular tonsillitis is characterized by inflammation of the palatine tonsils with visible white or yellow follicles (exudates) on the tonsillar surface. It's important to differentiate between viral and bacterial causes:
- Bacterial tonsillitis: 5-15% of cases in adults and 15-30% in children aged 5-15 years, primarily caused by Group A beta-hemolytic streptococcus (GABHS) 1
- Viral tonsillitis: 70-95% of cases 1
Diagnostic approach:
- Validated scoring systems (e.g., Centor score) to assess probability of GABHS
- Throat culture or rapid antigen detection test to confirm bacterial etiology
- Clinical features suggesting bacterial infection: fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough
Treatment Recommendations
First-line Treatment for Bacterial Tonsillitis
- Penicillin V: 250mg three times daily for 10 days 1
- Remains the drug of choice despite increasing failure rates (now approximately 30%) 2
- Complete 10-day course is essential to prevent rheumatic fever
Alternative Treatments (for penicillin-allergic patients)
Azithromycin: 12mg/kg once daily for 5 days (pediatric) or 500mg once daily for 3 days (adult) 3, 4
- Clinical success rates of 94-98% at 30 days post-treatment 3
- Convenient dosing schedule improves compliance
- FDA-approved for pharyngitis/tonsillitis with documented effectiveness
Clarithromycin: 500mg twice daily for 10 days 4
- Lower rates of gastrointestinal side effects compared to erythromycin
Viral Tonsillitis Management
- Supportive care only
- Antibiotics should be avoided if viral etiology is confirmed or strongly suspected 5
- Symptomatic relief: adequate hydration, analgesics, antipyretics, salt water gargles
Treatment Efficacy and Considerations
- Azithromycin has demonstrated superior bacteriologic eradication rates compared to penicillin in clinical trials (95% vs 73% at Day 14) 3
- The primary cause of penicillin treatment failure may be poor compliance with the 10-day regimen 2
- Short-course therapy with newer antibiotics like azithromycin may improve compliance and outcomes 4
Common Pitfalls and Caveats
- Overtreatment: Treating viral tonsillitis with antibiotics contributes to antibiotic resistance
- Undertreatment: Inadequate duration of therapy for bacterial tonsillitis increases risk of complications
- Misdiagnosis: Relying solely on clinical appearance without appropriate testing
- Compliance issues: Failure to complete the full course of antibiotics
Follow-up Recommendations
- Re-evaluate if symptoms persist beyond 3-5 days of appropriate therapy
- Consider tonsillectomy for recurrent episodes (7+ episodes in past year, 5+ episodes per year for 2 years, or 3+ episodes per year for 3 years) 1
- Monitor for potential complications: peritonsillar abscess, rheumatic fever, glomerulonephritis
Special Populations
- Children: Azithromycin dosing is weight-based at 12mg/kg once daily for 5 days for pharyngitis/tonsillitis 3
- Pregnant women: Penicillin remains the safest option if treatment is necessary
By following these evidence-based recommendations, clinicians can effectively manage follicular tonsillitis while minimizing complications and antibiotic resistance.