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 for 10 days as an acceptable alternative. 1, 2

Diagnostic Approach

Before initiating antibiotics, you must confirm bacterial infection through testing:

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

Critical pitfall to avoid: Do not initiate antibiotic therapy without confirming GAS infection through testing 2, 3

First-Line Antibiotic Treatment

For confirmed GAS tonsillitis:

• Penicillin V for 10 days is the drug of choice 1, 2
• Amoxicillin for 10 days is an acceptable alternative first-line treatment 1, 2
• The full 10-day course is necessary to maximize bacterial eradication and prevent complications like rheumatic fever and acute glomerulonephritis 1, 2, 3

Do not use shorter courses of penicillin (less than 10 days) as this increases risk of treatment failure 2, 3

Alternative Antibiotics for Penicillin-Allergic Patients

If the patient has a penicillin allergy, acceptable alternatives include:

• Cephalexin 1
• Cefadroxil 1
• Clindamycin 1
• Azithromycin 1
• Clarithromycin 1

Important caveat: Macrolides (azithromycin, clarithromycin) should not be used as first-line treatment when penicillin can be used 2. In pediatric patients with pharyngitis/tonsillitis, azithromycin 12 mg/kg once daily for 5 days has been studied and shown clinical efficacy 4

Supportive Care

Regardless of etiology:

• Acetaminophen for pain relief before and after any intervention 5
• Ibuprofen or acetaminophen for pain control 1
• NSAIDs (e.g., ibuprofen) are appropriate for symptom management 6

Viral Tonsillitis Management

• Supportive care only - no antibiotics 7, 8
• Topical therapies may relieve sore throat and shorten disease duration 9
• 70-95% of tonsillitis cases are viral 8

Indications for Tonsillectomy

Watchful waiting is recommended if the patient has had fewer than 7 episodes in the past year, fewer than 5 episodes per year for 2 years, or fewer than 3 episodes per year for 3 years 5, 2, 3

Consider tonsillectomy when recurrent throat infections meet the Paradise criteria 5, 2, 3:

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

Each episode must be documented with at least one of the following 1, 2:

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

All episodes should be disabling, adequately treated, and well-documented 3

Post-Tonsillectomy Care

If tonsillectomy is performed:

• Single intraoperative dose of dexamethasone for pain relief 5, 3
• Ibuprofen, acetaminophen, or both for postoperative pain control 1
• Follow-up to document presence or absence of bleeding 1
• Monitor for primary and secondary hemorrhage 5, 1

Common Pitfalls to Avoid

• Never prescribe antibiotics for viral tonsillitis 2
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2, 3
• Never perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 3
• Never perform tonsillectomy without meeting appropriate criteria for frequency and severity of episodes 3
• Never use shorter antibiotic courses (less than 10 days) for GAS tonsillitis 2, 3