What is the treatment for acute tonsillitis?

Treatment of Acute Tonsillitis

For acute tonsillitis, test first with rapid antigen detection testing (RADT) or throat culture for Group A Streptococcus (GAS), then treat confirmed bacterial cases with penicillin V or amoxicillin for 10 days, while viral cases require only supportive care with NSAIDs or acetaminophen. 1, 2

Diagnostic Approach: Test Before Treating

• Always confirm GAS infection before prescribing antibiotics using RADT and/or throat culture to avoid unnecessary antibiotic use, as most tonsillitis cases are viral 1, 2, 3
• Bacterial tonsillitis presents with sudden onset sore throat, fever >38°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and prominent cervical lymphadenopathy 2, 3
• Do not perform microbiological screening in asymptomatic children, as 10% of healthy children carry streptococcus pyogenes without clinical significance 4

Treatment Algorithm for Confirmed GAS Tonsillitis

First-Line Antibiotic Therapy

• Penicillin V 250 mg orally four times daily for 10 days is the gold standard for confirmed GAS tonsillitis in adults 1, 2, 5
• Amoxicillin is an acceptable alternative with similar efficacy and better compliance due to less frequent dosing 2, 6
• For children, use 30-50 mg/kg/day of penicillin or amoxicillin in divided doses for 10 days 5, 4
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even though symptoms may resolve earlier 1, 2, 4

Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: Use first-generation cephalosporins 2
• For anaphylactic penicillin allergy: Use clindamycin, azithromycin, or clarithromycin 2
• Azithromycin dosing: 12 mg/kg once daily for 5 days in children, or 500 mg on day 1 followed by 250 mg daily for days 2-5 in adults 6
• Erythromycin dosing: 250 mg four times daily in adults or 30-50 mg/kg/day in divided doses for children, both for 10 days 5

Treatment Failure or Recurrent Cases

• For patients failing azithromycin or amoxicillin-clavulanate: Use clindamycin 20-30 mg/kg/day divided into 3 doses for 10 days (maximum 300 mg/dose) in children, or 600 mg/day divided into 2-4 doses for 10 days in adults 7, 8
• Amoxicillin-clavulanate shows superior microbiological eradication compared to penicillin in recurrent cases 8
• Consider that the patient may be a chronic GAS carrier experiencing intercurrent viral infections rather than true recurrent bacterial tonsillitis 1, 7

Symptomatic Management

• Ibuprofen or acetaminophen are recommended for pain relief and fever reduction 1
• Throat lozenges containing topical anesthetics (ambroxol, lidocaine, benzocaine) may provide temporary relief, but represent a choking hazard in young children 1
• Warm salt water gargles are commonly used but lack robust evidence 1
• Corticosteroids are NOT routinely recommended for acute tonsillitis, though a single dose may benefit adults with severe presentations (Centor score 3-4) when combined with antibiotics 1

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing to prevent unnecessary antibiotic exposure and resistance 1, 2
• Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis despite symptom resolution, as only 10-day therapy prevents rheumatic fever 2, 4
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2
• Do not perform routine post-treatment throat cultures in asymptomatic patients who completed appropriate therapy 1, 7
• Do not treat chronic GAS carriers with antibiotics, as they are at very low risk for complications and unlikely to spread infection 1, 7

When to Consider Tonsillectomy

• Tonsillectomy may be considered when meeting Paradise criteria: ≥7 episodes in the past year, OR ≥5 episodes per year for 2 consecutive years, OR ≥3 episodes per year for 3 consecutive years 2, 7
• Each documented episode must include fever, cervical adenopathy, tonsillar exudate, or positive GAS test 2, 7
• Tonsillectomy is NOT recommended solely to reduce the frequency of GAS pharyngitis according to IDSA guidelines (strong recommendation, high-quality evidence) 1, 7
• Watchful waiting is appropriate if episodes are fewer than these thresholds 2

Follow-Up Considerations

• Routine follow-up cultures are not indicated for asymptomatic patients who completed appropriate antibiotic therapy 2, 7
• If symptoms persist despite appropriate therapy, consider medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics 2, 7
• Distinguish between true recurrent GAS infections (rising anti-streptococcal antibody titers) and chronic carriers experiencing viral pharyngitis (no rising titers) 1, 7