Do All Cases of Tonsillitis Require Antibiotics?
No, not all cases of tonsillitis require antibiotics—only those with confirmed or highly probable Group A Streptococcus (GAS) infection should receive antibiotic therapy. 1, 2
Distinguishing Bacterial from Viral Tonsillitis
The majority of tonsillitis cases (>65%) are viral in origin and do not benefit from antibiotics. 2, 3 The key is identifying which patients have bacterial infection, specifically GAS.
Clinical Scoring Systems
Use the Centor criteria (or modified McIsaac score) to stratify patients by probability of GAS infection. 1, 2 Award points for:
- Fever ≥38°C (+1 point) 1, 4
- Tonsillar exudates (+1 point) 1, 4
- Tender anterior cervical lymphadenopathy (+1 point) 1, 4
- Absence of cough (+1 point) 1, 4
- Age <15 years (+1 point) 1
- Age ≥45 years (-1 point) 1
Management Based on Score
- Score 0-1: Do NOT test or treat with antibiotics 1, 2
- Score 2-3: Perform rapid antigen detection test (RADT) or throat culture; treat only if positive 1
- Score 4+: Either initiate antibiotics immediately OR perform confirmatory testing 1
Critical pitfall: Patients with viral features (cough, rhinorrhea, hoarseness, oral ulcers, conjunctivitis) should NOT be tested for GAS regardless of score, as these strongly suggest viral etiology. 1, 3
When Antibiotics ARE Indicated
Confirmed GAS Infection
Antibiotics should be prescribed ONLY when GAS is confirmed by RADT or throat culture. 1, 2 This approach:
- Shortens symptom duration by only 1-2 days 2
- Reduces risk of suppurative complications 2
- Decreases contagiousness 2
- Prevents rheumatic fever (though incidence is now only 0.5 per 100,000 school-age children) 5, 6
First-Line Antibiotic Choice
Penicillin V remains the first-line antibiotic due to narrow spectrum, efficacy, tolerability, and cost. 1 Standard regimen is:
The 10-day duration is essential for preventing rheumatic fever and glomerulonephritis, even though shorter courses (3-5 days) may achieve similar symptom relief and bacterial clearance. 5, 6
Alternative Antibiotics
For penicillin-allergic patients, azithromycin is FDA-approved as an alternative, though it should be used cautiously given resistance concerns. 7 Cephalosporins and macrolides have shown effectiveness, particularly in penicillin treatment failures. 1, 8
Symptomatic Treatment for ALL Patients
Regardless of antibiotic use, all patients should receive analgesic therapy with acetaminophen or NSAIDs (ibuprofen) for pain and fever control. 1, 2, 3 Additional supportive measures include:
- Warm salt water gargles (for those old enough) 3
- Topical anesthetics (ambroxol, lidocaine, benzocaine) for temporary relief 3
- Avoid aspirin in children due to Reye syndrome risk 3
Common Pitfalls to Avoid
- Do NOT prescribe antibiotics without confirming GAS infection through clinical scoring and/or testing 4, 2
- Do NOT confuse GAS carriers (10% of healthy children) with active infection—carriers have positive tests but no clinical symptoms and should NOT be treated 5, 6
- Do NOT perform screening tests in asymptomatic children, even if requested by schools or daycare centers 5, 6
- Do NOT use shorter antibiotic courses (<10 days) if the goal is preventing rheumatic fever, despite adequate symptom control 5, 6
Special Considerations
Recurrent Tonsillitis
For patients with truly recurrent bacterial tonsillitis (≥7 episodes in 1 year, ≥5 per year for 2 years, or ≥3 per year for 3 years), tonsillectomy becomes the appropriate intervention rather than repeated antibiotic courses. 4, 9
Severe Presentations
Patients with severe symptoms (difficulty swallowing, drooling, neck tenderness/swelling) require evaluation for peritonsillar abscess, parapharyngeal abscess, epiglottitis, or Lemierre syndrome—these are medical emergencies requiring urgent intervention beyond simple antibiotics. 1, 2