What is the best treatment for tonsillitis in pregnant women?

Treatment of Tonsillitis in Pregnancy

Penicillin antibiotics are the first-line treatment for bacterial tonsillitis in pregnant women, with cephalosporins as an appropriate alternative for those with non-anaphylactic penicillin allergy. 1

Diagnosis and Etiology

• Tonsillitis is caused by viral infections in 70-95% of cases, with bacterial infections (primarily Group A beta-hemolytic streptococcus) accounting for 5-15% of cases in adults 2
• Accurate diagnosis is crucial to differentiate between viral and bacterial causes, as treatment approaches differ significantly 3
• Clinical assessment should include evaluation of symptoms such as sore throat, difficulty swallowing, and physical examination for tonsillar swelling and exudate 4

Treatment Algorithm

For Viral Tonsillitis (70-95% of cases):

• Supportive care is the mainstay of treatment 4
• Safe symptomatic relief options include:
  • Saline gargles for throat discomfort 1
  • Acetaminophen (paracetamol) for pain and fever control 1
  • Adequate hydration and rest 4

For Bacterial Tonsillitis (5-30% of cases):

First-line treatment:

• Penicillin antibiotics are the safest and most effective option during pregnancy 1, 5
  • Penicillin G or Ampicillin are preferred due to their narrow spectrum of activity and established safety profile 6

For penicillin-allergic patients:

• For non-anaphylactic penicillin allergy:
  • First-generation cephalosporins (e.g., cefazolin) are recommended 1, 6
• For patients with history of anaphylaxis to penicillin:
  • Clindamycin can be used if the bacterial isolate is susceptible 6
  • Erythromycin is an alternative if the isolate is susceptible 6
  • Vancomycin may be used when susceptibility testing is not available or isolates are resistant to clindamycin and erythromycin 6

Medications to Avoid During Pregnancy

• Tetracyclines should not be administered after the fifth week of pregnancy 5
• Aminoglycosides should be avoided due to associated nephrotoxicity and ototoxicity 5
• Fluoroquinolones are contraindicated during pregnancy 1, 5
• Trimethoprim-sulfamethoxazole should be avoided 1, 5
• Oral decongestants should not be used, especially during the first trimester, due to potential association with congenital malformations 6

Special Considerations

• For severe infections or complications, consultation with an obstetrician is recommended 1
• When treating bacterial tonsillitis, the full course of antibiotics should be completed to prevent complications such as rheumatic fever or glomerulonephritis 2
• Intranasal corticosteroids may be safely used for associated nasal symptoms, with budesonide, fluticasone, and mometasone considered safe during pregnancy 6

Common Pitfalls to Avoid

• Failing to differentiate between viral and bacterial causes can lead to unnecessary antibiotic use 2
• Assuming all antibiotics have equivalent safety profiles during pregnancy is incorrect - penicillins and cephalosporins have the best safety data 5
• First trimester carries the highest risk for medication-induced teratogenicity, so non-urgent treatments should be carefully evaluated during this period 6
• Untreated severe bacterial tonsillitis can lead to complications that may affect both maternal and fetal health 2