Treatment of Tonsillitis
Penicillin V for 10 days is the first-line treatment for confirmed Group A Streptococcal (GAS) tonsillitis, with amoxicillin for 10 days as an acceptable alternative. 1, 2, 3
Diagnosis
- Testing with rapid antigen detection test (RADT) and/or throat culture for Group A Streptococcus (GAS) should be performed before initiating antibiotics 1, 2
- Bacterial tonsillitis presents with sudden onset of sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 2
- Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy 2
First-Line Treatment for Bacterial Tonsillitis
- Penicillin V for 10 days remains the gold standard treatment for confirmed GAS tonsillitis 1, 2, 3
- Amoxicillin for 10 days is an equivalent alternative first-line treatment 1, 2, 3
- The standard 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1, 2
- Short courses (5 days) of penicillin are less effective for GAS eradication and should be avoided 2, 3
Treatment for Penicillin-Allergic Patients
- For non-anaphylactic penicillin allergy: first-generation cephalosporins (cefalexin, cefadroxil) for 10 days 2, 3
- For anaphylactic penicillin allergy: clindamycin, azithromycin, or clarithromycin 2, 3
- Azithromycin has been shown to be effective in the eradication of susceptible strains of Streptococcus pyogenes, but some strains are resistant 4
Management of Recurrent Tonsillitis
- For recurrent documented GAS tonsillitis, consider alternative regimens such as clindamycin, amoxicillin-clavulanate, or penicillin with rifampin 2, 3
- Clindamycin (20-30 mg/kg/day in 3 doses, maximum 300 mg/dose) for 10 days is recommended for documented recurrent GAS tonsillitis within 2 weeks of completing standard therapy 2
- Alternative regimens include amoxicillin-clavulanate (40 mg amoxicillin/kg/day in 3 doses) for 10 days 2
- Penicillin with rifampin: Penicillin V for 10 days plus rifampin for the last 4 days of treatment 2
Criteria for Watchful Waiting vs. Surgical Intervention
- Watchful waiting is 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 1, 3
- Consider tonsillectomy for recurrent, documented episodes of bacterial tonsillitis that meet specific frequency criteria: 7 or more episodes in the preceding year, or 5 or more episodes in each of the 2 preceding years 1, 3, 5
- Tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterial tonsillitis 5
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 1
- Using shorter courses of penicillin (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 1, 2
- Performing tonsillectomy solely to reduce the frequency of GAS pharyngitis without meeting established frequency criteria 1, 2
- Routine follow-up cultures for asymptomatic patients who completed appropriate therapy 2