What is the recommended treatment for palatine tonsillitis?

Treatment for Palatine Tonsillitis

Diagnostic Confirmation Required Before Treatment

Before initiating antibiotics, confirm Group A Streptococcus (GAS) infection through rapid antigen detection testing (RADT) and/or throat culture, as antibiotics should only be prescribed for confirmed bacterial cases. 1, 2

• Use the Centor/McIsaac criteria to guide testing: fever >38.3°C, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough 1, 2
• Patients with 0-2 Centor criteria should NOT receive antibiotics, as viral etiology is most likely 1
• Patients with 3-4 Centor criteria warrant testing and consideration of antibiotics if GAS-positive 1
• Common pitfall: Prescribing antibiotics based on clinical appearance alone without microbiological confirmation leads to unnecessary antibiotic use in 70-95% of cases that are viral 3

First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis

Penicillin V remains the first-line treatment: 250 mg twice or three times daily in children, or 250 mg four times daily or 500 mg twice daily in adolescents/adults for 10 days. 1, 2

• Amoxicillin is an acceptable alternative: 50 mg/kg once daily (maximum 1000 mg) or 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2
• Benzathine penicillin G intramuscular is an option when compliance is questionable: 600,000 units for patients <27 kg or 1,200,000 units for patients ≥27 kg as a single dose 1
• The 10-day duration is critical to maximize bacterial eradication and prevent complications like rheumatic fever; shorter courses (5 days) of standard-dose penicillin are less effective 2, 4
• GAS has shown no resistance to penicillin over five decades, making it the optimal narrow-spectrum choice 1

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy, use first-generation cephalosporins: cephalexin 20 mg/kg twice daily (maximum 500 mg per dose) or cefadroxil 30 mg/kg once daily (maximum 1 g) for 10 days. 1, 2

• Avoid cephalosporins in patients with immediate-type hypersensitivity (anaphylaxis) to penicillin 1
• For anaphylactic penicillin allergy, use clindamycin 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 2
• Alternative macrolides include azithromycin 12 mg/kg once daily (maximum 500 mg) for 5 days or clarithromycin 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1, 5
• Important caveat: Macrolide resistance varies geographically and temporally; approximately 1% of azithromycin-susceptible isolates become resistant following therapy 1, 5

Management of Recurrent Tonsillitis After Recent Treatment

For patients with documented GAS tonsillitis recurring within 2 weeks of completing standard therapy, use clindamycin 20-30 mg/kg/day in 3 divided doses (maximum 300 mg/dose) for 10 days. 1, 2

• Alternative regimens include amoxicillin-clavulanate 40 mg/kg/day (amoxicillin component) in 3 divided doses for 10 days 1, 2
• Benzathine penicillin G intramuscular with rifampin 20 mg/kg/day for the final 4 days is another option 1, 2
• These regimens target beta-lactamase-producing bacteria that may shield GAS from penicillin 6
• Consider the possibility of chronic GAS carriage with intercurrent viral infections rather than true recurrent bacterial infection 1, 2

Symptomatic Treatment (All Patients)

All patients should receive symptomatic relief with NSAIDs (ibuprofen) or acetaminophen for pain and fever, regardless of whether antibiotics are prescribed. 2, 7

• Warm salt water gargles can provide additional relief for patients old enough to perform them 2
• Topical agents containing benzalkonium chloride, tyrothricin, and benzocaine may shorten disease duration and relieve sore throat 8

Watchful Waiting vs. Tonsillectomy for Recurrent Episodes

Recommend watchful waiting if there have been <7 episodes in the past year, <5 episodes per year for 2 years, or <3 episodes per year for 3 years. 1, 7, 4

• Tonsillectomy may be considered only when episodes meet or exceed these frequency thresholds AND each episode is documented with temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 1, 7
• Tonsillectomy is NOT recommended solely to reduce the frequency of GAS pharyngitis in patients not meeting these criteria 1, 4
• Modifying factors that may favor tonsillectomy despite not meeting frequency criteria include multiple antibiotic allergies/intolerance, PFAPA syndrome, or history of >1 peritonsillar abscess 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics without microbiological confirmation of GAS 1, 2, 4
• Never use courses shorter than 10 days for standard penicillin or amoxicillin, as this increases treatment failure risk 2, 4
• Do not perform follow-up throat cultures on asymptomatic patients who completed appropriate therapy 1, 2
• Do not use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2, 4
• Delayed antibiotic prescribing (waiting 48 hours after initial consultation) is a valid strategy showing no difference in complication rates compared to immediate treatment 1