What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

The recommended treatment for tonsillitis depends on whether it is viral or bacterial in origin, with antibiotics indicated only for confirmed bacterial cases, particularly those caused by Group A Streptococcus (GAS). 1, 2

Diagnosis: Differentiating Viral from Bacterial Tonsillitis

• Viral tonsillitis (70-95% of cases) typically presents without high fever, tonsillar exudate, or significant cervical lymphadenopathy 1, 3
• Bacterial tonsillitis, particularly GAS, presents with sudden onset of sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1
• Testing with rapid antigen detection test (RADT) and/or throat culture for GAS is recommended before initiating antibiotics 2, 1

Treatment for Bacterial Tonsillitis

First-line Treatment

• Penicillin V for 10 days is the first-line treatment for confirmed GAS tonsillitis 1, 2
• Amoxicillin for 10 days is an acceptable alternative first-line treatment 1, 2
• The standard 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1, 2, 4

For Penicillin-Allergic Patients

• Non-anaphylactic allergy: First-generation cephalosporins (cefalexin, cefadroxil) for 10 days 1, 2
• Anaphylactic allergy: Clindamycin, azithromycin, or clarithromycin 1, 5
• Azithromycin (12 mg/kg once daily for 5 days) has shown clinical and microbiological superiority to penicillin in some studies 5

For Treatment Failures

• For recurrent documented GAS tonsillitis, consider clindamycin (30-40 mg/kg/day in 3 doses for 10 days) 1
• Alternative options include amoxicillin-clavulanate or penicillin with rifampin 1

Treatment for Viral Tonsillitis

• Supportive care is the mainstay of treatment for viral tonsillitis 6, 7
• Analgesic therapy with NSAIDs (ibuprofen), acetaminophen, and throat lozenges to help reduce pain 2, 1
• Warm salt water gargles for symptomatic relief 1
• Adequate hydration 6
• Antibiotics should not be prescribed for viral tonsillitis 2

Management of Recurrent Tonsillitis

• Watchful waiting is strongly recommended if there have been fewer than 7 episodes in the past year, fewer than 5 episodes per year for 2 years, or fewer than 3 episodes per year for 3 years 2, 3
• Tonsillectomy may be considered for recurrent, documented episodes of bacterial tonsillitis that meet specific frequency criteria (≥7 episodes in the past year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years) 2, 1
• Documentation should include temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for GAS 2

Common Pitfalls to Avoid

• Initiating antibiotic therapy without confirming GAS infection through testing 1, 2
• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 2
• Prescribing antibiotics for viral tonsillitis, which represents 70-95% of cases 3, 2
• Using shorter courses of penicillin (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 2, 1, 4
• Performing tonsillectomy solely to reduce the frequency of GAS pharyngitis without meeting established frequency criteria 2

Special Considerations

• For children younger than 2 years with acute otitis media (which can accompany tonsillitis), a standard 10-day course of antibiotics is recommended 2
• For children 2-5 years with mild or moderate acute otitis media, a 7-day course may be sufficient 2
• Penicillin failure rates in streptococcal tonsillopharyngitis have increased from 2-10% in the 1970s to approximately 30% currently, often due to lack of compliance with the 10-day regimen 4