What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

For bacterial tonsillitis, a 10-day course of penicillin remains the standard treatment to ensure clinical cure and prevent complications such as rheumatic fever, while supportive care is appropriate for viral tonsillitis. 1

Diagnosis and Etiology

• Tonsillitis is inflammation of the tonsils, accounting for approximately 0.4% of outpatient visits in the United States 2
• 70-95% of tonsillitis cases are viral in origin, requiring only supportive care 2
• Bacterial tonsillitis, primarily caused by Group A β-hemolytic streptococcus (GABHS), accounts for 5-15% of cases in adults and 15-30% in children aged 5-15 years 2
• Diagnosis should include documentation of symptoms plus at least one of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for GABHS 1

Treatment Algorithm for Tonsillitis

For Viral Tonsillitis:

• Supportive care with adequate hydration 3
• Pain management with acetaminophen or ibuprofen 1, 4
• Avoid unnecessary antibiotics 3

For Bacterial Tonsillitis (GABHS):

First-line treatment:

• Penicillin V for 10 days remains the standard treatment 1
  • Children: 250 mg 2-3 times daily
  • Adolescents/adults: 250 mg 4 times daily or 500 mg twice daily 1
• The 10-day duration is crucial for preventing rheumatic fever and other non-suppurative complications 1, 5

Alternative treatments for penicillin-allergic patients:

• Clindamycin for 10 days 1
  • Children: 20-30 mg/kg/day in 3 divided doses
  • Adults: 600 mg/day in 2-4 divided doses
• Macrolides (with caution due to resistance concerns) 1, 6
  • Azithromycin: 12 mg/kg once daily (max 500 mg) for 5 days 1, 4
  • Clarithromycin: 7.5 mg/kg twice daily (max 250 mg per dose) for 10 days 1

For treatment failures or recurrent infections:

• Amoxicillin-clavulanate for 10 days 1
  • Children: 40 mg/kg/day in 3 divided doses
  • Adults: 500 mg twice daily
• Cephalosporins may be more effective than penicillin for eradication in treatment failures 1, 7

Special Considerations

• Pain management: Recommend ibuprofen and/or acetaminophen for post-tonsillitis pain 1, 4
• Steroids: A single intraoperative dose of dexamethasone is recommended if surgical intervention is needed 1
• Antibiotics duration: While shorter courses (5 days) of high-dose penicillin (4 times daily) may be non-inferior for clinical cure, the standard 10-day course is still recommended to prevent complications 1
• Penicillin failure: Bacteriologic failure rates with penicillin have increased to approximately 30% since the 1970s, possibly due to poor compliance, reexposure, copathogenicity, or penicillin tolerance 7

Surgical Management (Tonsillectomy)

Tonsillectomy should be considered for:

• Recurrent throat infections meeting Paradise criteria 1:
  • ≥7 episodes in the past year, OR
  • ≥5 episodes per year for 2 years, OR
  • ≥3 episodes per year for 3 years
• Each episode must be documented with temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive GABHS test 1
• Watchful waiting is strongly recommended if frequency criteria are not met 1

Common Pitfalls to Avoid

• Inadequate duration: Do not shorten standard penicillin therapy to less than 10 days, as this increases risk of treatment failure and complications 1
• Overuse of antibiotics: Avoid prescribing antibiotics for viral tonsillitis 3, 2
• Macrolide resistance: Be aware of increasing resistance in GABHS when considering macrolides 1
• Unnecessary tonsillectomy: Surgery should be reserved for cases meeting specific frequency criteria; watchful waiting is appropriate for less severe cases 1
• Codeine use: Never administer or prescribe codeine for pain management in children under 12 years after tonsillectomy 1