What are the treatment options for tonsillitis?

From the Guidelines

Tonsillitis treatment should prioritize supportive care for viral cases and antibiotics for bacterial cases, with tonsillectomy considered for recurrent or complicated cases, as recommended by the most recent guidelines 1.

Treatment Approach

The approach to treating tonsillitis depends on whether the cause is viral or bacterial. For viral tonsillitis, which accounts for most cases, treatment focuses on supportive care including:

• Rest
• Adequate hydration
• Warm salt water gargles
• Over-the-counter pain relievers such as acetaminophen (325-650mg every 4-6 hours) or ibuprofen (400-600mg every 6-8 hours) to reduce pain and fever.

Bacterial Tonsillitis Treatment

For bacterial tonsillitis, particularly strep throat, antibiotics are necessary. First-line treatments include:

• Penicillin V (500mg twice daily for 10 days for adults)
• Amoxicillin (500mg twice daily for 10 days) For penicillin-allergic patients, alternatives include:
• Clindamycin (300mg three times daily for 10 days)
• Macrolides like azithromycin (500mg on day 1, then 250mg daily for 4 more days)

Tonsillectomy Consideration

Tonsillectomy may be recommended for patients with recurrent throat infection, defined as at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, with documentation in the medical record for each episode of sore throat and one of the following: temperature > 38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus, as suggested by recent clinical practice guidelines 1.

Additional Considerations

Home remedies that may help include:

• Throat lozenges
• Cold foods like popsicles
• Avoiding irritants such as smoking It's crucial to complete the full antibiotic course even if symptoms improve to prevent complications like rheumatic fever. Symptoms typically improve within 3-4 days of starting appropriate treatment. The decision to treat should be based on the presence of symptoms suggestive of group A streptococcal pharyngitis and confirmed by rapid antigen detection test and/or culture for group A Streptococcus, as advised by high-value care recommendations 1.

From the FDA Drug Label

In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) Pharyngitis/Tonsillitis (dosage regimen: 12 mg/kg on Days 1 to 5) Safety and effectiveness in the treatment of pediatric patients with pharyngitis/tonsillitis under 2 years of age have not been established. In the treatment of streptococcal infections of the upper respiratory tract (e.g., tonsillitis or pharyngitis), the therapeutic dosage of erythromycin should be administered for at least ten days.

The treatment options for tonsillitis include:

• Azithromycin: 12 mg/kg once a day for 5 days for pediatric patients, and 500 mg once daily for 3 days for adult patients 2
• Penicillin V: 250 mg three times a day for 10 days 2
• Erythromycin: the therapeutic dosage should be administered for at least ten days 3

From the Research

Treatment Options for Tonsillitis

The treatment options for tonsillitis are focused on supportive care and antibiotic therapy if a bacterial infection is identified.

• Supportive care is the primary treatment for viral tonsillitis, which accounts for 70% to 95% of cases 4.
• If group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic 4.
• In cases of recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years 4.

Antibiotic Treatment

• Penicillin is still considered the antibiotic of choice for the therapy of group A beta-hemolytic streptococci (GABHS) tonsillitis 5.
• However, other antibiotics such as cephalosporins, clindamycin, macrolides, and amoxicillin-clavulanate have been found to be more effective in eradicating the infection, especially in patients who have failed previous penicillin therapy 5.
• A 5-day course of cefuroxime axetil has been shown to be at least as effective as a 10-day course of penicillin V in treating tonsillopharyngitis due to GABHS 6.
• Clindamycin has been found to be effective in eradicating GABHS colonization and preventing recurrent tonsillitis 7.

Management of Recurrent Tonsillitis

• Patients with a history of recurrent tonsillitis due to GABHS may benefit from treatment with clindamycin, which has been shown to be effective in eradicating GABHS colonization and preventing recurrent tonsillitis 7.
• Tonsillectomy may be considered in cases of recurrent tonsillitis, especially if the patient has experienced seven or more episodes in the past year, five or more episodes per year for the past two years, or three or more episodes per year for the past three years 4.