What is the recommended management for tonsillitis?

Management of Tonsillitis

The first-line treatment for tonsillitis is to determine whether it's viral or bacterial through rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS), with antibiotics prescribed only for confirmed bacterial cases. 1, 2

Diagnosis of Tonsillitis

• Bacterial tonsillitis is characterized by sudden onset of sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2
• Viral tonsillitis typically presents without high fever, tonsillar exudate, and cervical lymphadenopathy 1
• Rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus should be performed to confirm bacterial infection before initiating antibiotics 1, 2

Treatment of Bacterial Tonsillitis

First-line Treatment

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

For Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: first-generation cephalosporins (cephalexin, cefadroxil) for 10 days 3, 2
• For anaphylactic penicillin allergy: clindamycin (7 mg/kg/dose three times daily, max 300 mg/dose) for 10 days 3, 2
• Alternative options include azithromycin (12 mg/kg once daily, max 500 mg) for 5 days or clarithromycin (7.5 mg/kg/dose twice daily, max 250 mg/dose) for 10 days 3, 4, 5

Management of Recurrent Tonsillitis

• For recurrent documented GAS tonsillitis, consider alternative regimens such as clindamycin, amoxicillin-clavulanate, or penicillin with rifampin 2
• Watchful waiting is 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, 6
• Tonsillectomy should be considered when episodes meet Paradise criteria: 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 1, 7
• Tonsillectomy is not recommended solely to reduce the frequency of GAS pharyngitis 3, 2

Supportive Care

• Symptomatic relief can be provided with NSAIDs (e.g., ibuprofen) for pain and fever 2, 7
• A single intraoperative dose of dexamethasone is recommended for pain relief in surgical cases 1, 7
• Warm salt water gargles can provide symptomatic relief for patients old enough to do so 2

Follow-up Recommendations

• Follow-up throat cultures are not recommended for asymptomatic patients who have completed appropriate antibiotic therapy 1, 2
• If symptoms persist despite appropriate antibiotic therapy, consider medication compliance issues, possibility of chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotic regimens 1, 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
• Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 1, 2
• Routine follow-up cultures for asymptomatic patients who completed appropriate therapy 1, 2
• Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 1, 7