What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

For confirmed bacterial (Group A Streptococcus) tonsillitis, penicillin V for 10 days is the first-line treatment, with amoxicillin as an equally acceptable alternative; antibiotics should only be prescribed after microbiological confirmation via rapid antigen detection testing (RADT) or throat culture. 1, 2, 3

Diagnostic Confirmation Before Treatment

• Always confirm Group A Streptococcus (GAS) infection through RADT and/or throat culture before prescribing antibiotics 1, 2, 3, 4
• Use the Centor/McIsaac criteria to guide testing: fever >38°C, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough 2, 3
• Patients with 0-2 Centor criteria should not receive antibiotics as viral etiology is most likely 3
• Patients with 3-4 Centor criteria warrant testing and consideration of antibiotics only if GAS-positive 3
• Never prescribe antibiotics without microbiological confirmation 3, 4

First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis

Penicillin V (First Choice)

• Children: 250 mg twice or three times daily for 10 days 1, 3
• Adolescents/Adults: 250 mg four times daily OR 500 mg twice daily for 10 days 1, 3

Amoxicillin (Equally Acceptable First-Line)

• Dosing: 50 mg/kg once daily (maximum 1000 mg) OR 25 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 2, 3

Critical Duration Point

• The 10-day duration is mandatory to maximize bacterial eradication and prevent complications like rheumatic fever 1, 2, 3, 4
• Short courses (5 days) of standard-dose penicillin are less effective for GAS eradication and should be avoided 2

Treatment for Penicillin-Allergic Patients

Non-Anaphylactic Penicillin Allergy

• First-generation cephalosporins (avoid in immediate-type hypersensitivity) 1, 2, 3
• Cephalexin: 20 mg/kg twice daily (maximum 500 mg per dose) for 10 days 1, 3
• Cefadroxil: 30 mg/kg once daily (maximum 1 g) for 10 days 1, 3

Anaphylactic Penicillin Allergy

• Clindamycin: 7 mg/kg three times daily (maximum 300 mg per dose) for 10 days 1, 2, 3
• Azithromycin: 12 mg/kg once daily (maximum 500 mg) for 5 days 1, 5
• Clarithromycin: 7.5 mg/kg twice daily (maximum 250 mg per dose) for 10 days 1
• Important caveat: Macrolide resistance varies geographically and temporally; consider local resistance patterns 1

Management of Recurrent Tonsillitis

Treatment Failure or Early Recurrence (Within 2 Weeks)

• Clindamycin: 20-30 mg/kg/day in 3 divided doses (maximum 300 mg/dose) for 10 days 2, 3
• Amoxicillin-clavulanate: 40 mg/kg/day (amoxicillin component) in 3 divided doses for 10 days 2, 3
• Consider that the patient may be a chronic GAS carrier experiencing intercurrent viral infections rather than recurrent bacterial tonsillitis 2

Indications for Tonsillectomy

• Watchful waiting is recommended if episodes are: 1, 2, 3, 4
  • <7 documented episodes in the past year
  • <5 episodes per year for 2 years
  • <3 episodes per year for 3 years
• Tonsillectomy may be considered when meeting Paradise criteria: ≥7 documented episodes in the past year, ≥5 per year for 2 years, OR ≥3 per year for 3 years 1, 2
• Each documented episode must include sore throat PLUS at least one of: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 1, 2
• Tonsillectomy is NOT recommended solely to reduce the frequency of GAS pharyngitis 1, 4

Symptomatic Treatment (For All Patients)

• NSAIDs (ibuprofen) or acetaminophen for pain and fever control 1, 2, 3
• Warm salt water gargles for patients old enough to perform them 2
• Never use codeine or codeine-containing medications in children younger than 12 years after tonsillectomy 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics without microbiological confirmation of GAS 2, 3, 4
• Never use courses shorter than 10 days for standard penicillin or amoxicillin, as this increases treatment failure risk and does not prevent rheumatic fever 2, 3, 4
• Do not use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 2, 4
• Do not perform follow-up throat cultures on asymptomatic patients who completed appropriate therapy 1, 2, 3
• Do not treat GAS carriers (asymptomatic patients with positive tests) as they are unlikely to spread infection or develop complications 1, 2
• Up to 20% of asymptomatic school-age children may be GAS carriers during winter and spring 2