What is the treatment for acute tonsillitis or pharyngitis?

Treatment of Acute Tonsillitis/Pharyngitis

Penicillin V for 10 days is the first-line treatment for confirmed bacterial tonsillitis, particularly Group A Streptococcal (GAS) infections, while viral tonsillitis should be managed with supportive care only. 1, 2, 3

Diagnostic Approach

• Differentiate between viral and bacterial tonsillitis using clinical criteria and testing before initiating antibiotics 2, 3
• Use Centor/McIsaac criteria to estimate probability of bacterial infection: fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 2, 4
• Perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus to confirm bacterial infection before prescribing antibiotics 3, 5
• Viral tonsillitis typically presents without high fever, tonsillar exudate, and cervical lymphadenopathy 2, 6

Treatment Algorithm

For Confirmed Bacterial Tonsillitis (GAS positive)

• First-line treatment: Penicillin V orally for 10 days 1, 2, 3

  • The standard 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1, 2
  • Short courses (5 days) of penicillin are less effective for GAS eradication and should be avoided 1, 2

• Alternative first-line treatment: Amoxicillin for 10 days 2, 3

  • Particularly useful in younger children due to better taste and availability as syrup 1

• For penicillin-allergic patients (non-anaphylactic): First-generation cephalosporins (cefalexin, cefadroxil) for 10 days 2

• For penicillin-allergic patients (anaphylactic): Clindamycin, azithromycin, or clarithromycin 2, 7

  • Azithromycin for pharyngitis/tonsillitis in children: 12 mg/kg once daily for 5 days 7

For Viral Tonsillitis

• Supportive care only - no antibiotics 1, 6
• NSAIDs (e.g., ibuprofen) for pain and fever relief 2
• Adequate hydration 6

Important Considerations

• Antibiotics should not be used in patients with less severe presentation (0-2 Centor criteria) 1
• For patients with 3-4 Centor criteria, modest benefits of antibiotics (1-2 days reduction in symptoms) must be weighed against side effects, impact on microbiota, antibiotic resistance, and costs 1
• Delayed antibiotic prescribing (waiting 48+ hours) is a valid option in ambiguous cases 1, 4
• Follow-up throat cultures are not recommended for asymptomatic patients who have completed appropriate antibiotic therapy 2, 3

Management of Recurrent Tonsillitis

• For recurrent documented GAS tonsillitis, consider alternative regimens such as clindamycin, amoxicillin-clavulanate, or penicillin with rifampin 2, 8
• Consider tonsillectomy for patients with recurrent, documented episodes that meet Paradise criteria: 7+ episodes in the preceding year, 5+ episodes per year for 2 consecutive years, or 3+ episodes per year for 3 consecutive years 3, 8

Common Pitfalls to Avoid

• Initiating antibiotic therapy without confirming GAS infection through testing 2, 3
• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2, 3
• Inadequate duration of antibiotic therapy (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 1, 3
• Routine follow-up cultures for asymptomatic patients who completed appropriate therapy 2, 3
• Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 3, 8