Treatment of Tonsillitis

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

Diagnosis

Before initiating treatment, it's crucial to determine whether the tonsillitis is bacterial or viral:

Bacterial tonsillitis typically presents with:
- Sudden onset of sore throat
- Fever >38°C
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough 1, 2
Viral tonsillitis usually presents without high fever, tonsillar exudate, and cervical lymphadenopathy 1
Rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) should be performed to confirm bacterial infection before starting antibiotics 1, 2

First-line antibiotic therapy:
- Penicillin V for 10 days 3, 1, 2
- Amoxicillin for 10 days is an acceptable alternative 3, 1, 4
- The standard 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1, 2
For penicillin-allergic patients:
- Cephalexin, clindamycin, or azithromycin 2
Symptomatic treatment:
- Ibuprofen and/or acetaminophen for pain control 2, 5
- A single dose of dexamethasone may be beneficial for pain relief in severe cases 2, 5

Supportive care only:
- Adequate hydration 6
- Pain management with NSAIDs (e.g., ibuprofen) or acetaminophen 5
- No antibiotics needed 7, 6

Watchful waiting is recommended if there have been:
- Fewer than 7 episodes in the past year
- Fewer than 5 episodes per year for the past 2 years
- Fewer than 3 episodes per year for the past 3 years 1, 2
Consider tonsillectomy 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, 2, 8
- All episodes should be disabling, adequately treated, and well-documented 1, 2

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

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, 9
Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure and complications 1, 2
Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 1, 2
Failure to recognize that beta-lactamase-producing bacteria may "shield" GAS and contribute to treatment failure in some cases 10