How to manage one-sided tonsillitis with a negative throat culture?

Management of One-Sided Tonsillitis with Negative Throat Culture

For one-sided tonsillitis with a negative throat culture, provide symptomatic treatment only without antibiotics, as this presentation is most likely viral in nature or due to a non-streptococcal pathogen. 1

Diagnostic Considerations

• Tonsillitis is caused by viral infections in 70-95% of cases, with bacterial infections (primarily Group A Streptococcus) accounting for only 5-15% of cases in adults 2
• A negative throat culture effectively rules out Group A Streptococcal (GAS) pharyngitis, which is the primary bacterial cause requiring antibiotic treatment 3
• Unilateral presentation may suggest alternative diagnoses that should be considered:
  • Viral infection with asymmetric presentation 4
  • Possible anaerobic infection (rare) such as Prevotella species 5
  • In rare cases, consider other causes like Chlamydia trachomatis, which may require specific testing if suspected 6
• Always exclude more serious conditions that can present with unilateral findings:
  • Peritonsillar abscess
  • Tonsillar malignancy
  • Infectious mononucleosis 5

Treatment Approach

First-Line Management (Symptomatic Treatment)

• Withhold or discontinue antimicrobial therapy for patients with negative throat cultures for GAS 3, 1
• Provide symptomatic relief measures:
  • Adequate hydration 4
  • Analgesics/antipyretics (acetaminophen or NSAIDs) 3
  • Warm salt water gargles, though limited studies exist on efficacy 3
  • Topical anesthetics (sprays, lozenges containing lidocaine or benzocaine) may provide temporary relief 3

When to Consider Additional Testing

• If symptoms persist beyond the expected viral course (3-5 days) or worsen:
  • Consider testing for less common pathogens 5
  • Re-evaluate for development of complications such as peritonsillar abscess 2
• For recurrent episodes of one-sided tonsillitis with negative cultures:
  • Consider the possibility of a chronic GAS carrier state with intercurrent viral infections 3
  • Evaluate for other infectious or non-infectious causes 5

Special Considerations for Recurrent Episodes

• Patients with recurrent episodes may be experiencing multiple viral infections or could be GAS carriers experiencing viral infections 3
• GAS carriers generally do not require antimicrobial therapy as they are unlikely to spread GAS pharyngitis and have little to no risk for developing complications 3
• Tonsillectomy is not recommended solely to reduce frequency of GAS pharyngitis 3, but may be considered for truly recurrent cases that meet specific criteria 2

Common Pitfalls to Avoid

• Prescribing antibiotics for negative throat cultures - this contributes to antimicrobial resistance and exposes patients to unnecessary side effects 1
• Failing to consider other diagnoses when presentation is unilateral and persistent 5
• Assuming all exudative tonsillitis requires antibiotics - viral causes are much more common, even with exudates 2, 4
• Ordering unnecessary follow-up cultures after treatment of a viral pharyngitis 3

Remember that most cases of tonsillitis, including those with unilateral presentation and negative throat cultures, are self-limiting viral infections that will resolve with supportive care alone 4.