What is the treatment for tonsillitis?

Treatment of Tonsillitis

For confirmed bacterial (Group A Streptococcus) tonsillitis, prescribe penicillin V for 10 days as first-line therapy; for recurrent tonsillitis meeting Paradise criteria (≥7 episodes in 1 year, ≥5 per year for 2 years, or ≥3 per year for 3 years), consider tonsillectomy after appropriate documentation. 1

Diagnostic Approach: Test Before Treating

• Always perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus before prescribing antibiotics, as most tonsillitis cases are viral and do not require antimicrobial therapy 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, 2

• Never initiate antibiotics without confirming GAS infection through testing—this is a critical pitfall that drives unnecessary antibiotic resistance 1, 3

Medical Treatment for Confirmed Bacterial Tonsillitis

First-Line Antibiotic Therapy

• Penicillin V for 10 days is the gold standard treatment for confirmed GAS tonsillitis 1, 3

• Amoxicillin for 10 days is an acceptable alternative first-line option 1, 3

• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even though shorter courses may resolve symptoms 1, 2, 4

Penicillin-Allergic Patients

• For non-anaphylactic penicillin allergy: use first-generation cephalosporins 1

• For anaphylactic penicillin allergy: use clindamycin, azithromycin, or clarithromycin 1

• Azithromycin (12 mg/kg once daily for 5 days in children, or adult dosing) was clinically and microbiologically superior to penicillin V in controlled trials, with 95% bacteriologic eradication at Day 14 versus 73% for penicillin 5

Adjunctive Symptomatic Treatment

• Administer acetaminophen for pain relief before and after any intervention 6

• Consider NSAIDs (e.g., ibuprofen) for symptom control 4

• A single intraoperative dose of dexamethasone is recommended for surgical cases 6, 2

Surgical Treatment: Tonsillectomy Indications

Watchful Waiting Criteria

• Recommend watchful waiting if episodes are fewer than 7 in the past year, fewer than 5 per year for 2 years, or fewer than 3 per year for 3 years 6, 1, 2, 3

Paradise Criteria for Tonsillectomy

Tonsillectomy is an option when recurrent throat infections meet all four Paradise criteria 6:

1. Frequency: ≥7 well-documented episodes in the preceding year, OR ≥5 episodes per year for 2 consecutive years, OR ≥3 episodes per year for 3 consecutive years 6, 1

2. Clinical features: Each episode must include sore throat plus at least one of the following: temperature >38.3°C (101°F), cervical adenopathy, tonsillar exudate, or positive test for GAS 1

3. Treatment: Episodes were treated with antibiotics when indicated 6

4. Documentation: Episodes are documented in the medical record by a clinician 6, 1

Special Surgical Considerations

• In children under 6 years, tonsillectomy should only be performed for recurrent acute bacterial tonsillitis meeting Paradise criteria 4

• For tonsillar hyperplasia without recurrent infection, partial tonsillectomy (tonsillotomy) should be first-line therapy, as it has lower postoperative pain and hemorrhage risk 4

• Total extracapsular tonsillectomy remains indicated for severely affected children with recurrent infections, antibiotic allergy, PFAPA syndrome, or peritonsillar abscess 4

Follow-Up and Monitoring

• Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1, 2

• If symptoms persist despite appropriate therapy, consider medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics 1, 2

• Ten percent of healthy children carry Streptococcus pyogenes in their tonsils without clinical signs; decolonization is not necessary in asymptomatic carriers 4

Critical Pitfalls to Avoid

• Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis—only the 10-day regimen has proven effective in preventing rheumatic fever (current incidence 0.5 per 100,000 school-age children) 1, 3, 4

• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 3

• Never perform tonsillectomy without meeting appropriate frequency and documentation criteria—this is a common overuse pattern with significant morbidity risk 1, 2, 3

• Recognize that microbiological screening tests in asymptomatic children are senseless and do not justify antibiotic treatment 4

• Be aware that beta-lactamase-producing bacteria can shield GAS from penicillin in up to 20% of treatment failures; consider alternative antibiotics (cephalosporins, clindamycin, macrolides, or amoxicillin-clavulanate) for patients who failed previous penicillin therapy 7