What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

For confirmed bacterial tonsillitis, penicillin V for 10 days is the first-line treatment, with amoxicillin for 10 days as an acceptable alternative. 1, 2, 3

Diagnosis

• Test with rapid antigen detection test (RADT) and/or throat culture for Group A Streptococcus (GAS) before initiating antibiotics 2, 3
• Bacterial tonsillitis typically presents with:
  • Sudden onset of sore throat
  • Fever >38°C (101°F)
  • Tonsillar exudates
  • Tender anterior cervical lymphadenopathy
  • Absence of cough 2, 3

Treatment Algorithm for Bacterial Tonsillitis

First-line Treatment

• Penicillin V for 10 days 1, 2, 3

  • Children: 250 mg 2-3 times daily
  • Adolescents and adults: 250 mg 4 times daily or 500 mg twice daily

• Amoxicillin for 10 days (alternative first-line) 1, 2

  • 50 mg/kg once daily (maximum 1000 mg) or
  • 25 mg/kg twice daily (maximum 500 mg per dose)

• Benzathine penicillin G (intramuscular, single dose) 1

  • <27 kg: 600,000 U
  • ≥27 kg: 1,200,000 U

For Penicillin-Allergic Patients

• Non-anaphylactic allergy: 1, 3

  • Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days

• Anaphylactic allergy: 1, 3, 4

  • Clindamycin: 7 mg/kg 3 times daily (maximum 300 mg per dose) for 10 days
  • Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days
  • Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days

Management of Recurrent Tonsillitis

• Tonsillectomy may be recommended for recurrent throat infection with: 1, 2

  • At least 7 episodes in the past year, OR
  • At least 5 episodes per year for 2 years, OR
  • At least 3 episodes per year for 3 years

• Each episode must be documented in the medical record with at least one of the following: 1

  • Temperature >38.3°C (101°F)
  • Cervical adenopathy
  • Tonsillar exudate
  • Positive test for GAS

• Watchful waiting is recommended if frequency criteria are not met 1, 2, 5

Treatment for Viral Tonsillitis

• Supportive care is the mainstay of treatment 6, 5
• Ibuprofen and/or acetaminophen for pain control 1
• Adequate hydration and rest 3

Important Considerations and Pitfalls

Avoid These Common Mistakes

• Initiating antibiotics without confirming GAS infection through testing 2, 3
• Using broad-spectrum antibiotics when narrow-spectrum penicillins are effective 2, 3
• Prescribing shorter courses of penicillin (less than 10 days) for GAS tonsillitis, which increases risk of treatment failure 2, 3, 7
• Performing tonsillectomy solely to reduce the frequency of GAS pharyngitis without meeting established frequency criteria 1, 2
• Administering or prescribing codeine or any medication containing codeine after tonsillectomy in children younger than 12 years 1

Treatment Failures

• Penicillin treatment failures have increased to approximately 30% in recent years 8, 7

• Causes include:

  • Poor compliance with 10-day regimen 8, 7
  • Reexposure to infected family members 8
  • Beta-lactamase-producing bacteria protecting GAS 7
  • Eradication of normal protective pharyngeal flora 8, 7

• For treatment failures, consider: 3, 7

  • Amoxicillin-clavulanate
  • Clindamycin
  • Second or third-generation cephalosporins

Post-Tonsillectomy Care

• Recommend ibuprofen, acetaminophen, or both for pain control 1
• Follow up with patients/caregivers and document presence or absence of bleeding 1
• Monitor for primary bleeding (within 24 hours) and secondary bleeding (after 24 hours) 1

The treatment approach should focus on accurate diagnosis, appropriate antibiotic selection for bacterial cases, and careful consideration of tonsillectomy only for patients meeting specific frequency criteria.