Treatment of Tonsillitis
Diagnostic Approach
Before initiating any antibiotic therapy, confirm bacterial infection with rapid antigen detection test (RADT) and/or throat culture for Group A Streptococcus (GAS). 1, 2, 3
Clinical Features Distinguishing Bacterial from Viral Tonsillitis
Bacterial tonsillitis typically presents with: 1, 2, 3
- Sudden onset of sore throat
- Fever >38.3°C
- Tonsillar exudates
- Tender anterior cervical lymphadenopathy
- Absence of cough (key distinguishing feature)
Viral tonsillitis presents without high fever, tonsillar exudate, and cervical lymphadenopathy. 2
Use Clinical Scoring Systems
Apply Centor, McIsaac, or FeverPAIN scores to estimate probability of bacterial infection before testing. 4 In ambiguous cases after scoring, proceed with point-of-care GAS testing. 4
First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis
Penicillin V for 10 days (twice or three times daily) is the recommended first-line treatment. 5, 1, 2, 3
Amoxicillin for 10 days is an acceptable alternative first-line option. 1, 2, 3 The clinical cure rates for amoxicillin and penicillin are comparable (86% vs 92% respectively). 5
Critical Duration Consideration
The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis. 2, 3 While shorter courses (3-7 days) may provide symptom relief, only the 10-day regimen has proven efficacy in preventing serious complications like rheumatic heart disease. 5, 6 Treatment for 7 days was superior to 3 days in resolving symptoms. 5
Alternative Antibiotics for Penicillin-Allergic Patients
For patients with penicillin allergy, use: 1
- Cephalexin
- Cefadroxil
- Clindamycin
- Azithromycin
- Clarithromycin
Azithromycin demonstrates comparable efficacy to penicillin with clinical success rates of 98% at Day 14 and 94% at Day 30, compared to 84% and 74% for penicillin. 7 However, azithromycin showed higher gastrointestinal side effects (18% vs 13% for penicillin). 7
Symptomatic Management
Combine analgesics for pain control: 6
- NSAIDs (ibuprofen)
- Acetaminophen
- Dexamethasone for additional symptom relief 6
Management of Treatment Failure
If symptoms persist despite appropriate 10-day antibiotic therapy, consider: 2
- Medication compliance issues
- Chronic GAS carriage with intercurrent viral infection
- Beta-lactamase-producing bacteria (BLPB) that "shield" GAS from penicillin 8
For penicillin treatment failures, switch to antibiotics effective against BLPB: 8
- Cephalosporins (any generation)
- Amoxicillin-clavulanate
- Clindamycin
Beta-lactamase-producing bacteria were recovered from over 75% of tonsils in patients with recurrent infections. 8
Indications for Tonsillectomy (Paradise Criteria)
Tonsillectomy is indicated when recurrent tonsillitis meets the following frequency criteria with documented episodes: 1, 2, 3
- ≥7 episodes in the preceding year, OR
- ≥5 episodes per year for 2 consecutive years, OR
- ≥3 episodes per year for 3 consecutive years
Each episode must be documented with at least one of: 1
- Temperature >38.3°C
- Cervical adenopathy
- Tonsillar exudate
- Positive GAS test
All episodes must be disabling, adequately treated, and well-documented in the medical record. 2
Watchful waiting is appropriate if episodes fall below these thresholds. 2, 3
Critical Pitfalls to Avoid
Never initiate antibiotics without confirming GAS infection through testing. 2, 3 Approximately 10% of healthy children carry streptococcus pyogenes asymptomatically without clinical disease, making empiric treatment inappropriate. 6
Never use antibiotic courses shorter than 10 days for GAS tonsillitis as this increases treatment failure risk and does not prevent rheumatic fever. 2, 3
Never perform routine follow-up throat cultures in asymptomatic patients who completed appropriate therapy. 2, 3
Never prescribe broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS. 3
Never perform tonsillectomy without meeting established Paradise criteria frequency thresholds. 2, 3