What is the recommended treatment for bacterial tonsillitis?

Treatment of Bacterial Tonsillitis

Penicillin V remains the first-line antibiotic for bacterial tonsillitis caused by Group A Streptococcus, administered for 10 days at 250 mg twice or three times daily in children, or 250 mg four times daily or 500 mg twice daily in adolescents and adults. 1, 2

First-Line Treatment Options

For patients without penicillin allergy:

• Penicillin V oral is the gold standard due to its proven efficacy, narrow spectrum, safety profile, and low cost 1, 2

  • Children: 250 mg twice or three times daily for 10 days 1
  • Adolescents/adults: 250 mg four times daily OR 500 mg twice daily for 10 days 1

• Amoxicillin is an equally effective alternative with better compliance due to once-daily dosing 1, 2

  • 50 mg/kg once daily (maximum 1000 mg) for 10 days 1, 2
  • Alternative: 25 mg/kg twice daily (maximum 500 mg/dose) for 10 days 1, 2

• Benzathine penicillin G intramuscular provides single-dose treatment, ensuring complete compliance 1, 2

  • <27 kg: 600,000 units as single dose 1
  • ≥27 kg: 1,200,000 units as single dose 1

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy:

• First-generation cephalosporins are preferred 2, 3
  • Cephalexin: 20 mg/kg/dose twice daily (maximum 500 mg/dose) for 10 days 1, 2
  • Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1, 2
  • Avoid in patients with immediate-type hypersensitivity (anaphylaxis) to penicillin 1, 2

For anaphylactic penicillin allergy:

• Clindamycin: 7 mg/kg/dose three times daily (maximum 300 mg/dose) for 10 days 1, 2, 3

• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 2, 4

  • Important caveat: Geographic resistance of Group A Streptococcus to macrolides varies significantly 1, 2
  • Susceptibility testing should be performed when using azithromycin 4
  • Azithromycin does NOT have established efficacy in preventing rheumatic fever 4

• Clarithromycin: 7.5 mg/kg/dose twice daily (maximum 250 mg/dose) for 10 days 1, 2

  • Same resistance concerns as azithromycin 1, 2

Critical Treatment Duration Considerations

The standard 10-day course is essential for most antibiotics:

• 10-day treatment maximizes bacterial eradication and prevents complications including acute rheumatic fever 1, 2, 3
• Short courses (5 days) of standard-dose penicillin are inadequate and should be avoided 3, 5
• The only exception is high-dose penicillin V (800 mg four times daily for 5 days), though this is not standard practice 3, 5
• Azithromycin and some cephalosporins may be effective with shorter courses, but 10-day regimens remain the standard recommendation 2, 3

Management of Treatment Failure or Recurrent Tonsillitis

If symptoms return within 2 weeks of completing therapy:

• Consider treatment failure, chronic GAS carriage with viral superinfection, or reinfection 3

• First-line options for documented recurrent GAS tonsillitis 3, 6:

  • Clindamycin: 20-30 mg/kg/day in 3 divided doses (maximum 300 mg/dose) for 10 days 3
  • Amoxicillin-clavulanate: 40 mg amoxicillin/kg/day in 3 divided doses (maximum 2000 mg amoxicillin/day) for 10 days 3, 6
  • Penicillin V 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 3

• These regimens target beta-lactamase producing organisms and improve tissue penetration 6, 7

Role of Tonsillectomy

Tonsillectomy is NOT recommended solely to reduce the frequency of GAS pharyngitis 1, 3

Consider tonsillectomy only for:

• ≥7 documented episodes in the past year, OR 8
• ≥5 episodes per year for 2 consecutive years, OR 8
• ≥3 episodes per year for 3 consecutive years 8
• Each episode must be documented with temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 8

Essential Supportive Care

All patients require symptomatic treatment regardless of antibiotic use:

• NSAIDs (ibuprofen) or acetaminophen for pain and fever control 3, 8
• Warm salt water gargles for patients old enough to perform them 3

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through rapid antigen detection test (RADT) or throat culture 3, 8
• Do not use broad-spectrum antibiotics when narrow-spectrum penicillins are effective 3
• Avoid inadequate treatment duration (<10 days for most antibiotics), which increases treatment failure risk 3, 5
• Do not perform routine follow-up cultures in asymptomatic patients who completed appropriate therapy 3
• Remember that azithromycin lacks proven efficacy in preventing rheumatic fever, unlike penicillin 4