What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

For confirmed bacterial tonsillitis, treat with penicillin V 250 mg four times daily (or 500 mg twice daily) for 10 days, or amoxicillin for 10 days as an acceptable alternative. 1, 2

Diagnosis Before Treatment

• Always confirm Group A Streptococcus (GAS) infection before initiating antibiotics using rapid antigen detection test (RADT) and/or throat culture 1, 2
• Bacterial tonsillitis typically presents with sudden onset of sore throat, fever >38.3°C (101°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2
• Use clinical scoring systems (Centor, McIsaac, or FeverPAIN) to estimate probability of bacterial infection 3
• Do not initiate antibiotics without confirming GAS infection - 70-95% of tonsillitis cases are viral and do not require antibiotics 4

First-Line Antibiotic Treatment

For confirmed GAS tonsillitis:

• Penicillin V: 250 mg four times daily OR 500 mg twice daily for 10 days 1, 2, 5
• Amoxicillin: Standard dosing for 10 days is an acceptable first-line alternative 1, 2
• The full 10-day course is mandatory to maximize bacterial eradication and prevent complications including rheumatic fever, acute glomerulonephritis, and peritonsillar abscess 2
• Twice-daily dosing of penicillin is as efficacious as more frequent dosing and improves compliance 6

For pediatric patients:

• Penicillin or amoxicillin: 30-50 mg/kg/day in divided doses for 10 days 5
• For severe infections, dosing may be doubled but should not exceed 4 g/day 5

Penicillin-Allergic Patients

Alternative antibiotics include:

• Cephalexin or cefadroxil (first-generation cephalosporins) 1
• Clindamycin 1
• Azithromycin: 12 mg/kg once daily for 5 days (pediatric) or 500 mg on day 1, then 250 mg daily for days 2-5 (adult) 1, 7
• Clarithromycin 1
• Erythromycin: 250 mg four times daily or 500 mg twice daily for 10 days 1, 5

Important caveat: Azithromycin demonstrated clinical superiority to penicillin V in controlled trials (98% vs 84% clinical success at day 14), but approximately 1% of susceptible S. pyogenes isolates became resistant following azithromycin therapy 7

Supportive Care

• Combination of acetaminophen and/or ibuprofen for pain control 1
• Supportive care is the primary treatment for viral tonsillitis 4, 8

Management of Recurrent Tonsillitis

Watchful waiting is strongly recommended if episodes are:

• <7 episodes in the past year, OR 9, 2
• <5 episodes per year for the past 2 years, OR 9, 2
• <3 episodes per year for the past 3 years 9, 2

Tonsillectomy may be considered when:

• ≥7 documented episodes in the past year, OR 9, 1, 2
• ≥5 documented episodes per year for 2 years, OR 9, 1, 2
• ≥3 documented episodes per year for 3 years 9, 1, 2

Each episode must be documented with:

• Temperature ≥38.3°C (101°F), AND 9, 1
• At least one of: cervical adenopathy, tonsillar exudate, or positive GAS test 9, 1

Modifying factors that may favor tonsillectomy despite not meeting frequency criteria:

• Multiple antibiotic allergies/intolerance 9
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, adenitis) 9
• History of >1 peritonsillar abscess 9

Critical Pitfalls to Avoid

• Never use penicillin courses shorter than 10 days - this increases treatment failure risk 2
• Never use once-daily penicillin dosing - it is associated with 12% lower cure rates compared to more frequent dosing 6
• Never prescribe broad-spectrum antibiotics when narrow-spectrum penicillins are effective 2
• Never perform tonsillectomy solely to reduce GAS pharyngitis frequency without meeting established criteria 2
• Never prescribe antibiotics for viral tonsillitis 2