What is the treatment for tonsillitis (tx)?

Treatment of Tonsillitis

For confirmed bacterial (Group A Streptococcus) tonsillitis, penicillin V 250-500 mg orally four times daily for 10 days remains the gold standard first-line treatment, with amoxicillin as an acceptable alternative. 1, 2, 3

Diagnostic Confirmation Before Treatment

Testing is mandatory before initiating antibiotics to distinguish bacterial from viral tonsillitis and prevent unnecessary antibiotic use. 2, 3

• Perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus before prescribing antibiotics 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, 3
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy 1, 3

First-Line Antibiotic Treatment Algorithm

For Non-Penicillin Allergic Patients:

Penicillin V: 1, 2, 3, 4

• Adults: 250-500 mg orally four times daily for 10 days 4
• Children: 30-50 mg/kg/day in divided doses for 10 days 4

Amoxicillin (acceptable alternative): 1, 2, 5

• Adults: 500 mg every 8 hours or 875 mg every 12 hours for 10 days 5
• Children ≥3 months and <40 kg: 25 mg/kg/day divided every 12 hours or 20 mg/kg/day divided every 8 hours for 10 days 5

For Penicillin-Allergic Patients:

Non-anaphylactic allergy: 1, 2, 3

• First-generation cephalosporins (cefalexin, cefadroxil) for 10 days 1

Anaphylactic allergy: 1, 2, 3

• Clindamycin, azithromycin, or clarithromycin 1, 2
• Erythromycin: Adults 250-500 mg four times daily for 10 days; Children 30-50 mg/kg/day in divided doses for 10 days 4, 6

Critical Treatment Duration Requirement

The full 10-day antibiotic course is mandatory and non-negotiable to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even though symptoms may resolve earlier. 1, 2, 3

• Short courses (5 days) of standard-dose penicillin are less effective for GAS eradication and should be avoided 7, 1, 3
• The only exception is high-dose penicillin (four times daily dosing) which may be given for 5 days, though this is not standard practice 7
• Short-course cephalosporins or macrolides may have better eradication rates than standard penicillin, but 10-day courses remain the standard recommendation 7, 6

Symptomatic Treatment

All patients should receive symptomatic relief regardless of antibiotic use: 7

• NSAIDs (ibuprofen) or acetaminophen for pain and fever 7
• Warm salt water gargles for patients old enough to perform them 1

Management of Treatment Failures and Recurrent Tonsillitis

For Documented Recurrent GAS Tonsillitis Within 2 Weeks of Completing Therapy:

Alternative antibiotic regimens targeting beta-lactamase producing bacteria: 1, 3, 8

• Clindamycin: 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days 1
• Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 doses (maximum 2000 mg amoxicillin/day) for 10 days 1, 3
• Penicillin with rifampin: Penicillin V 50 mg/kg/day in 4 doses for 10 days plus rifampin 20 mg/kg/day in 1 dose for the last 4 days 1

The rationale for these alternatives is that beta-lactamase-producing bacteria can "shield" GAS from penicillin, occurring in over 75% of recurrent cases. 8

Tonsillectomy Indications (Paradise Criteria):

Tonsillectomy should be considered when: 2, 3, 9

• ≥7 adequately treated, well-documented episodes in the preceding year, OR 2, 9
• ≥5 such episodes in each of the preceding 2 years, OR 2, 9
• ≥3 such episodes in each of the preceding 3 years 2, 9

Each documented episode must include temperature, cervical adenopathy, tonsillar exudate, or positive test for GAS. 2

Follow-Up Recommendations

• Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1, 2, 3
• If symptoms persist despite appropriate therapy, consider medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics 1, 3

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing - most cases are viral and do not require antibiotics 2, 3
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2, 3
• Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis (except high-dose penicillin regimens), as this increases treatment failure risk 1, 2, 3
• Never perform tonsillectomy without meeting appropriate frequency and documentation criteria per Paradise criteria 2
• Approximately 10% of healthy children are chronic GAS carriers without clinical disease - do not treat asymptomatic carriers identified through screening 10