What is the recommended treatment for severe tonsillitis?

Treatment for Severe Tonsillitis

For severe bacterial tonsillitis confirmed by rapid antigen detection test (RADT) or throat culture positive for Group A Streptococcus (GAS), treat with penicillin V for 10 days as first-line therapy, or amoxicillin for 10 days as an acceptable alternative. 1, 2

Diagnostic Confirmation Required Before Treatment

• Always test before treating with RADT and/or throat culture for GAS before initiating antibiotics—do not empirically treat based on clinical presentation alone 1, 2
• Bacterial tonsillitis typically presents with sudden onset of sore throat, fever >38.3°C, tonsillar exudates, tender anterior cervical lymphadenopathy, and notably the absence of cough 1, 2
• The presence of cough suggests viral etiology, which accounts for 70-95% of tonsillitis cases and requires only supportive care 3, 4

First-Line Antibiotic Treatment

• Penicillin V for 10 days is the gold standard first-line treatment recommended by the Infectious Diseases Society of America for confirmed GAS tonsillitis 1, 2
• Amoxicillin for 10 days is an acceptable alternative first-line option 1, 2
• The full 10-day course is necessary to maximize bacterial eradication and prevent serious complications including rheumatic fever, acute glomerulonephritis, peritonsillar abscess, and Lemierre syndrome 2

Alternative Antibiotics for Penicillin-Allergic Patients

For patients with documented penicillin allergy, the American Academy of Otolaryngology-Head and Neck Surgery recommends these alternatives 1:

• Cephalexin or cefadroxil (first-generation cephalosporins)
• Clindamycin
• Azithromycin
• Clarithromycin

Note: Azithromycin dosing for pediatric pharyngitis/tonsillitis is 12 mg/kg once daily for 5 days 5

Management of Treatment Failure

If the patient has failed initial antibiotic therapy (e.g., azithromycin and amoxicillin-clavulanate), the Infectious Diseases Society of America recommends clindamycin 20-30 mg/kg/day divided into 3 doses for 10 days in children (or 600 mg/day divided into 2-4 doses in adults) 6

Critical distinction: Differentiate between true recurrent GAS infections versus chronic GAS carrier state with intercurrent viral pharyngitis 6:

• True recurrent infections show rising anti-streptococcal antibody titers and require aggressive treatment
• Carriers lack immunologic response, are at very low risk for complications, and do not require antimicrobial therapy 6

Supportive Care Measures

• Provide adequate analgesia with acetaminophen or ibuprofen for pain and fever control 7, 4
• Ensure adequate hydration 4
• Educate caregivers about the importance of managing and reassessing pain 7

When to Consider Tonsillectomy

Tonsillectomy may be recommended for recurrent throat infection meeting the Paradise criteria with proper documentation 7, 1, 2:

• ≥7 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 in the medical record with temperature >38.3°C, cervical adenopathy, tonsillar exudate, or positive test for GAS 7, 1

Watchful waiting is strongly recommended if episodes fall below these thresholds, as spontaneous improvement commonly occurs—control groups in randomized trials showed reduction to only 0.3-1.17 episodes per year without surgery 7, 3

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing—viral tonsillitis does not benefit from antibiotics 2
• Never use antibiotic courses shorter than 10 days for penicillin or amoxicillin in GAS tonsillitis, as this increases treatment failure risk 2
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective 2
• Do not routinely test or treat asymptomatic contacts of patients with GAS tonsillitis 6
• Do not perform routine post-treatment cultures unless clinically indicated 6
• Do not perform tonsillectomy solely to reduce GAS pharyngitis frequency without meeting established Paradise criteria—the Infectious Diseases Society of America gives this a strong recommendation against (high-quality evidence) 6