What is the treatment for tonsillitis?

Treatment of Tonsillitis

For bacterial tonsillitis, penicillin V for 10 days is the first-line treatment, with amoxicillin for 10 days as an acceptable alternative. 1, 2

Diagnosis

• Differentiate between viral and bacterial tonsillitis through clinical presentation and testing 3:
  • Bacterial tonsillitis: sudden onset of sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough
  • Testing with rapid antigen detection test (RADT) and/or throat culture for Group A Streptococcus (GAS) before initiating antibiotics 1

Treatment Algorithm

First-line Treatment for Confirmed Bacterial Tonsillitis

• Penicillin V for 10 days 2, 1
• Amoxicillin for 10 days as an acceptable alternative 2, 1
• The standard 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1, 3

For Penicillin-Allergic Patients

• Non-anaphylactic allergy: First-generation cephalosporins (cefalexin, cefadroxil) for 10 days 3
• Anaphylactic allergy: Clindamycin, azithromycin, or clarithromycin 3
• Azithromycin has shown similar efficacy to penicillin in clinical trials for streptococcal pharyngitis 4

Adjunctive Therapy

• Steroids (e.g., dexamethasone) to reduce inflammation 5, 6
• NSAIDs (e.g., ibuprofen) for pain and fever relief 5, 6
• Warm salt water gargles for symptomatic relief 3

Treatment Duration Considerations

• Short courses (5 days) of penicillin are less effective for GAS eradication and should be avoided 3
• The 10-day course of antibiotics has proven effective in preventing rheumatic fever and glomerulonephritic diseases 5, 6
• Shorter courses of newer antibiotics (cephalosporins) may be effective but have more side effects 2

Management of Recurrent Tonsillitis

• For recurrent documented GAS tonsillitis, consider alternative regimens such as clindamycin, amoxicillin-clavulanate, or penicillin with rifampin 3
• Tonsillectomy should be considered for recurrent, disabling sore throat due to acute tonsillitis when episodes are well documented and meet the Paradise criteria 2:
  • 7+ episodes in the preceding year, OR
  • 5+ episodes per year for 2 consecutive years, OR
  • 3+ episodes per year for 3 consecutive years 5, 6

Common Pitfalls to Avoid

• Initiating antibiotic therapy without confirming GAS infection through testing 1, 3
• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1
• 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, 3
• Performing tonsillectomy solely to reduce the frequency of GAS pharyngitis without meeting established frequency criteria 1, 3

Special Considerations

• Bacterial immunotherapy combined with antibiotics may reduce the need for tonsillectomy in adults with recurrent tonsillitis 7
• Penicillin failure rates in streptococcal tonsillopharyngitis have increased over time, possibly due to lack of compliance with the 10-day regimen, reexposure to infected individuals, or penicillin tolerance 8
• In severe cases of acute tonsillitis, parenteral antibiotics (ampicillin + sulbactam) combined with daily cleaning of tonsillar lesions may significantly reduce recovery time 9