Treatment of Tonsillitis
For confirmed bacterial tonsillitis caused by Group A Streptococcus, prescribe penicillin V for 10 days as first-line treatment, or amoxicillin for 10 days as an acceptable alternative. 1, 2
Diagnostic Approach Before Treatment
Always confirm bacterial infection before initiating antibiotics to avoid unnecessary antibiotic use and resistance. 1, 3
- Perform rapid antigen detection test (RADT) and/or throat culture for Group A Streptococcus (GAS) before prescribing antibiotics 1, 2, 3
- Look for these specific clinical features suggesting bacterial tonsillitis: sudden onset of sore throat, fever >38°C (>38.3°C for documentation purposes), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 3
- Viral tonsillitis typically presents without high fever, tonsillar exudate, and cervical lymphadenopathy 3
Common pitfall: Do not initiate antibiotics without confirming GAS infection through testing, as 70-95% of tonsillitis cases are viral. 1, 3, 4
First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis
The standard treatment duration is 10 days—shorter courses increase treatment failure risk and do not adequately prevent complications like rheumatic fever. 1, 2, 3
Primary Options:
- Penicillin V for 10 days (first-line) 1, 2
- Amoxicillin for 10 days (acceptable alternative first-line) 1, 2
For Penicillin-Allergic Patients:
- Cephalexin, cefadroxil, clindamycin, azithromycin, or clarithromycin 2
- Note: Macrolides are not first-line treatment and should be reserved for penicillin-allergic patients 2
- Azithromycin demonstrated 98% clinical success at Day 14 and 94% at Day 30 in pediatric pharyngitis studies, compared to 84% and 74% respectively for penicillin V 5
Critical pitfall: Do not use shorter courses of penicillin (less than 10 days), which increases risk of treatment failure and inadequate bacterial eradication. 1, 3
Supportive Care
For viral tonsillitis or as adjunct to antibiotics for bacterial cases:
- Ibuprofen, acetaminophen, or both for pain control 2
- Topical agents (benzalkonium chloride + tyrothricin + benzocaine) may provide additional symptom relief and shorten disease duration 6
Management of Recurrent Tonsillitis
Watchful waiting is strongly recommended unless specific frequency criteria are met. 1, 3, 4
When to Observe (No Surgery):
- Fewer than 7 episodes in the past year 1, 3, 4
- Fewer than 5 episodes per year for 2 years 1, 3, 4
- Fewer than 3 episodes per year for 3 years 1, 3, 4
When to Consider Tonsillectomy:
Tonsillectomy is indicated when recurrent bacterial tonsillitis meets Paradise criteria: 2, 3, 7
- ≥7 documented episodes in the preceding year, OR
- ≥5 episodes per year for 2 consecutive years, OR
- ≥3 episodes per year for 3 consecutive years
Documentation Requirements for Each Episode:
Each episode must be documented with at least one of: 2
- Temperature >38.3°C
- Cervical adenopathy
- Tonsillar exudate
- Positive test for GAS
All episodes should be disabling, adequately treated, and well-documented. 3
Important pitfall: Do not perform tonsillectomy solely to reduce frequency of GAS pharyngitis without meeting established frequency criteria—this is ineffective and exposes patients to unnecessary surgical risks. 1, 3
Follow-Up Recommendations
- Do not perform follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 3
- If symptoms persist despite appropriate treatment, consider medication compliance issues, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotic regimens 3
Key Pitfalls to Avoid
- Never prescribe antibiotics for viral tonsillitis—this contributes to antibiotic resistance without clinical benefit 1
- Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 3
- Never prescribe antibiotics without diagnostic confirmation of bacterial infection 1, 3
- Never use inadequate antibiotic duration (less than 10 days for GAS) 1, 3