What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

For confirmed bacterial tonsillitis caused by Group A Streptococcus, prescribe penicillin V for 10 days as first-line therapy; for viral tonsillitis, provide supportive care only with NSAIDs or acetaminophen—no antibiotics. 1, 2

Diagnostic Approach: Distinguish Bacterial from Viral

Before initiating any antibiotic therapy, you must confirm the etiology through testing:

• Perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus before prescribing antibiotics 3, 1, 2
• Bacterial tonsillitis presents with: sudden onset sore throat, fever >38.3°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2
• Viral tonsillitis typically lacks: high fever, tonsillar exudate, and cervical lymphadenopathy 1

Critical pitfall: Do not prescribe antibiotics based on clinical appearance alone—up to 70-95% of tonsillitis cases are viral 4. Testing is mandatory to avoid inappropriate antibiotic use 3, 1.

Treatment for Confirmed Bacterial (Group A Streptococcus) Tonsillitis

First-Line Antibiotic Therapy

• Penicillin V: 250 mg orally four times daily for 10 days (adults) or 30-50 mg/kg/day in divided doses for 10 days (children) 1, 2, 5
• Alternative first-line: Amoxicillin 40 mg/kg/day in three divided doses for 10 days (children) or standard adult dosing 1, 2

The full 10-day course is non-negotiable—this duration maximizes bacterial eradication and prevents rheumatic fever, which remains the primary goal of treatment 1, 6. Short courses of 5 days with standard-dose penicillin are less effective and should be avoided 1.

For Penicillin-Allergic Patients

• Non-anaphylactic allergy: First-generation cephalosporins (cephalexin or cefadroxil) for 10 days 1, 2
• Anaphylactic allergy: Clindamycin, azithromycin, or clarithromycin 1, 2
  • Azithromycin: 12 mg/kg once daily for 5 days (maximum 500 mg/day) 7
  • Clarithromycin: twice daily dosing for 10 days 8
  • Erythromycin: 250 mg four times daily for 10 days (adults) or 30-50 mg/kg/day in divided doses (children) 5, 8

Important consideration: While newer macrolides (azithromycin, clarithromycin) offer better tolerability and shorter courses, approximately 1% of streptococcal isolates develop resistance following azithromycin therapy 7. Penicillin remains superior when tolerated.

Treatment for Viral Tonsillitis

• Provide supportive care only—no antibiotics 2, 9
• Analgesic therapy: Ibuprofen, acetaminophen, or both for pain and fever control 3, 2, 9
• Throat lozenges may provide additional symptomatic relief 3
• Ensure adequate hydration and rest 9

Patients can be reassured that viral tonsillitis typically resolves within one week without antibiotics 3.

Management of Recurrent Tonsillitis

When to Consider Tonsillectomy

Tonsillectomy is indicated when recurrent episodes meet Paradise criteria 3, 1, 2:

• ≥7 well-documented episodes in the past year, OR
• ≥5 episodes per year for 2 consecutive years, OR
• ≥3 episodes per year for 3 consecutive years

Each episode must be documented with at least one of the following: temperature ≥38.3°C, cervical adenopathy, tonsillar exudate, or positive GAS test 1, 2.

Watchful waiting is strongly recommended if episodes fall below these thresholds 3, 4. Tonsillectomy solely to reduce frequency of streptococcal pharyngitis is not recommended in adults 3.

Alternative Antibiotic Regimens for Treatment Failures

If symptoms return within 2 weeks of completing standard therapy:

• 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 for 10 days 1
• Penicillin V with rifampin: Standard penicillin dosing for 10 days plus rifampin 20 mg/kg/day for the last 4 days 1

Important caveat: Consider whether the patient is a chronic GAS carrier experiencing intercurrent viral infections rather than true recurrent bacterial tonsillitis 1. Up to 20% of asymptomatic school-age children may be GAS carriers during winter and spring 1.

Perioperative Management (If Tonsillectomy Indicated)

• Administer single intraoperative dose of IV dexamethasone (0.5 mg/kg) to decrease postoperative nausea, vomiting, and pain 3, 9
• Do not routinely administer perioperative antibiotics—evidence shows no benefit 3, 9
• Provide ibuprofen, acetaminophen, or both for postoperative pain control 3, 2
• Monitor for primary and secondary hemorrhage through follow-up with patients/caregivers 3, 2

Key Pitfalls to Avoid

• Never prescribe antibiotics without confirming bacterial infection through testing 3, 1, 9
• Never use antibiotic courses shorter than 10 days for confirmed GAS (except azithromycin 5-day course)—this increases treatment failure risk 1, 9
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 9
• Never order follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1
• Never base tonsillectomy decisions on ASO titers—these reflect past immunologic response, not current infection status 1