What is the management of tonsillitis?

Management of Tonsillitis

The management of tonsillitis should primarily focus on determining whether the infection is viral or bacterial, with antibiotics prescribed only for confirmed bacterial cases, particularly Group A Streptococcus (GAS), and tonsillectomy reserved for specific recurrent cases meeting Paradise criteria. 1, 2

Diagnosis

• Bacterial tonsillitis is characterized by sudden onset of sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 2
• Viral tonsillitis typically presents without high fever, tonsillar exudate, and cervical lymphadenopathy 2
• Rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus should be performed to confirm bacterial infection before initiating antibiotics 2, 3
• Clinical scoring systems like the Centor score can help guide testing decisions 4

Treatment of Acute Tonsillitis

Supportive Care (All Cases)

• NSAIDs such as ibuprofen for pain and fever reduction 2, 3
• Adequate hydration and rest 3
• Warm salt water gargles for symptomatic relief in older children and adults 2
• Single intraoperative dose of dexamethasone is recommended for pain relief in surgical cases 1

Antibiotic Treatment (For Bacterial Tonsillitis)

• First-line treatment for confirmed GAS tonsillitis:

  • Penicillin V for 10 days is the treatment of choice 5, 6
  • Amoxicillin is an acceptable alternative (50 mg/kg once daily, maximum 1000 mg, for 10 days) 5
  • The standard 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 5, 2

• For penicillin-allergic patients (non-anaphylactic):

  • First-generation cephalosporins like cephalexin (20 mg/kg twice daily, maximum 500 mg per dose, for 10 days) 5
  • Cefadroxil (30 mg/kg once daily, maximum 1 g, for 10 days) 5

• For penicillin-allergic patients (anaphylactic):

  • Clindamycin (7 mg/kg three times daily, maximum 300 mg per dose, for 10 days) 5
  • Azithromycin (12 mg/kg once daily, maximum 500 mg, for 5 days), noting potential resistance of GAS to macrolides 5, 7
  • Clarithromycin (7.5 mg/kg twice daily, maximum 250 mg per dose, for 10 days) 5

Management of Recurrent Tonsillitis

Watchful Waiting

• Watchful waiting is strongly recommended if there have been fewer than seven episodes in the past year, fewer than five episodes per year for the past two years, or fewer than three episodes per year for the past three years 1, 4

Antibiotic Options for Recurrent Cases

• For documented recurrent GAS tonsillitis within 2 weeks of completing standard therapy:
  • Clindamycin (20-30 mg/kg/day in 3 doses, maximum 300 mg/dose, for 10 days) 2
  • Amoxicillin-clavulanate (40 mg/kg/day in 3 doses, maximum 2000 mg amoxicillin/day, for 10 days) 2
  • Penicillin with rifampin: Penicillin V plus rifampin 20 mg/kg/day for the last 4 days of treatment 2

Tonsillectomy Considerations

• Tonsillectomy should be considered for recurrent tonsillitis when the episodes meet Paradise criteria: 1
  • 7 or more well-documented episodes in the preceding year, OR
  • 5 or more episodes per year for 2 consecutive years, OR
  • 3 or more episodes per year for 3 consecutive years
• All episodes should be disabling, adequately treated, and well-documented 1
• Tonsillectomy is not recommended solely to reduce the frequency of mild GAS pharyngitis 2
• For children under 6 years, tonsillectomy should only be performed for recurrent acute bacterial tonsillitis 3
• In cases of tonsillar hypertrophy without recurrent infection, partial tonsillectomy (tonsillotomy) should be considered as it has lower risks of hemorrhage and postoperative pain 3

Follow-up Recommendations

• Follow-up throat cultures are not recommended for asymptomatic patients who have completed appropriate antibiotic therapy 2
• If symptoms persist despite appropriate antibiotic therapy, consider:
  • Medication compliance issues 2
  • Possibility of chronic GAS carriage with intercurrent viral infections 2
  • Need for alternative antibiotic regimens 1

Common Pitfalls to Avoid

• Initiating antibiotic therapy without confirming GAS infection through testing 2
• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 5
• Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 5, 2
• Routine follow-up cultures for asymptomatic patients who completed appropriate therapy 2
• Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 1