What is the treatment approach for acute tonsillitis?

Treatment of Acute Tonsillitis

The treatment of acute tonsillitis should begin with determining whether the infection is viral or bacterial (particularly Group A Streptococcus), with antibiotics prescribed only for confirmed bacterial cases. 1, 2, 3

Diagnosis

• 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 2, 3
• Clinical scoring systems like Centor/McIsaac (taking into account age and presence of respiratory symptoms) can help guide testing decisions 4, 5

Treatment Algorithm

For Confirmed Bacterial Tonsillitis:

1. First-line antibiotic therapy:

   • Penicillin V for 10 days 1, 3
   • Amoxicillin for 10 days is an acceptable alternative 3, 6
   • The standard 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever 1, 3

2. For penicillin-allergic patients:

   • Non-anaphylactic allergy: First-generation cephalosporins (cefalexin, cefadroxil) for 10 days 1
   • Anaphylactic allergy: Clindamycin, azithromycin, or clarithromycin 1, 7

3. For treatment failures:

   • Amoxicillin-clavulanate 8, 1
   • Clindamycin 1
   • Second or third-generation cephalosporins 8

For Viral Tonsillitis:

1. Symptomatic treatment only:
   • NSAIDs (e.g., ibuprofen) for pain and fever 8, 9
   • Acetaminophen/paracetamol for pain and fever 8
   • Adequate hydration 9
   • Throat lozenges or warm salt water gargles 8, 1

Special Considerations

• For severe cases with difficulty swallowing, drooling, neck tenderness, or swelling, evaluate for rare throat infections like peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome 8
• Short courses (less than 10 days) of antibiotics are less effective for GAS eradication and should be avoided 1, 3
• Follow-up throat cultures are not recommended for asymptomatic patients who have completed appropriate antibiotic therapy 2, 3

Management of Recurrent Tonsillitis

• Consider tonsillectomy for recurrent, documented episodes of bacterial tonsillitis that meet Paradise criteria: 7 or more episodes in the preceding year, 5 or more episodes per year for 2 consecutive years, or 3 or more episodes per year for 3 consecutive years 2, 5
• For documented recurrent GAS tonsillitis within 2 weeks of completing standard therapy, consider alternative regimens such as clindamycin, amoxicillin-clavulanate, or penicillin with rifampin 1

Common Pitfalls to Avoid

• Initiating antibiotic therapy without confirming GAS infection through testing 8, 3
• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 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
• Performing tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 2, 5
• Prescribing antibiotics for viral tonsillitis, which represents the majority of cases 4, 9