What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

For confirmed bacterial tonsillitis caused by Group A Streptococcus, penicillin V for 10 days is the first-line treatment, with amoxicillin as an acceptable alternative, and antibiotics should only be initiated after confirming bacterial infection through rapid antigen detection testing (RADT) or throat culture. 1, 2

Diagnostic Approach

Before initiating any antibiotic therapy, you must confirm the etiology:

• Perform RADT and/or throat culture for Group A Streptococcus (GAS) before prescribing antibiotics 1, 2, 3
• Bacterial tonsillitis typically presents with: sudden onset sore throat, fever >38.3°C (100.9°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2, 3
• Viral tonsillitis (70-95% of cases) presents without high fever, tonsillar exudate, or significant cervical lymphadenopathy 3, 4

Common pitfall: Do not initiate antibiotics without confirming GAS infection through testing—this is inappropriate antibiotic stewardship and contributes to resistance 2, 3

First-Line Antibiotic Treatment for Confirmed GAS

When GAS is confirmed:

• Penicillin V for 10 days is the gold standard first-line treatment 1, 2
• Amoxicillin for 10 days is an acceptable alternative first-line option 1, 2
• The full 10-day course is mandatory to maximize bacterial eradication and prevent complications including rheumatic fever and acute glomerulonephritis 1, 2, 3

Critical warning: Shorter courses of penicillin (less than 10 days) increase the risk of treatment failure and do not adequately prevent rheumatic fever 2, 3

Alternative Antibiotics for Penicillin-Allergic Patients

For patients with documented penicillin allergy:

• Cephalexin 1
• Cefadroxil 1
• Clindamycin 1
• Azithromycin 1, 5
• Clarithromycin 1

For azithromycin dosing in children with pharyngitis/tonsillitis: 12 mg/kg once daily for 5 days (ages 2 years and above) 5

Supportive Care

Regardless of etiology:

• Acetaminophen for pain relief and fever control 6
• Ibuprofen for pain control 1
• Single intraoperative dose of dexamethasone if surgical intervention is required 6, 3

Management of Viral Tonsillitis

• Supportive care only—no antibiotics 7, 4
• Symptomatic treatment with analgesics and antipyretics
• Topical agents may provide symptom relief 8

Indications for Tonsillectomy in Recurrent Tonsillitis

Watchful waiting is strongly recommended if episodes do not meet the following Paradise criteria 6, 2, 3:

Tonsillectomy should be considered when recurrent throat infections are well-documented and meet these frequency thresholds:

• ≥7 episodes in the preceding year, OR
• ≥5 episodes per year for 2 consecutive years, OR
• ≥3 episodes per year for 3 consecutive years 6, 1, 2, 3

Each episode must be documented with at least one of the following:

• Temperature >38.3°C (100.9°F)
• Cervical adenopathy
• Tonsillar exudate
• Positive test for GAS 1, 3

All episodes must be disabling and adequately treated 3

Important caveat: If documentation is lacking, watchful waiting with prospective documentation of additional episodes is appropriate rather than proceeding directly to surgery 6

Follow-Up Recommendations

• Do not perform follow-up throat cultures in asymptomatic patients who completed appropriate antibiotic therapy 3
• If symptoms persist despite appropriate antibiotics, consider medication compliance issues, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotic regimens 3

Key Pitfalls to Avoid

• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2, 3
• Never prescribe antibiotics for viral tonsillitis 2
• Never perform tonsillectomy without meeting established frequency and severity criteria 2, 3
• Never use inadequate antibiotic duration (less than 10 days for penicillin/amoxicillin) as this increases treatment failure risk 2, 3