Treatment of Tonsillitis
For confirmed bacterial (Group A Streptococcus) tonsillitis, prescribe penicillin V 250 mg four times daily for 10 days, or amoxicillin as an alternative, after confirming the diagnosis with rapid antigen detection testing or throat culture. 1, 2
Diagnostic Approach: Test Before Treating
Always perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) before initiating any antibiotics, as the majority of tonsillitis cases are viral and do not require antibiotics 1, 2, 3
Bacterial tonsillitis presents with: sudden onset sore throat, fever >38°C (>38.3°C for documentation), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough 1, 2, 3
Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy 2, 3
Medical Treatment for Confirmed Bacterial Tonsillitis
First-Line Antibiotic Therapy
Penicillin V 250 mg four times daily (or 500 mg twice daily) for 10 days is the gold standard treatment 1, 2, 4
Amoxicillin for 10 days is an acceptable alternative first-line option 1, 2
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, 5
Penicillin-Allergic Patients
Non-anaphylactic penicillin allergy: Use first-generation cephalosporins 2
Anaphylactic penicillin allergy: Use clindamycin, azithromycin (12 mg/kg once daily for 5 days in children, or 500 mg daily for 3 days in adults), or clarithromycin 2, 6
Pediatric Dosing
Children: 30-50 mg/kg/day of erythromycin or penicillin equivalent in divided doses for 10 days 4
For azithromycin in children with pharyngitis/tonsillitis: 12 mg/kg once daily for 5 days 6
Supportive Care (For All Patients)
Acetaminophen or ibuprofen for pain and fever control 1
Ensure adequate hydration 1
Educate caregivers about pain management and when to reassess 1
Surgical Treatment: Tonsillectomy Indications
When to Consider Surgery
Tonsillectomy is indicated when the patient meets Paradise criteria with proper documentation 1, 2, 3:
- ≥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
Required Documentation for Each Episode
Each episode must be documented with 2, 3:
- Temperature >38.3°C
- Cervical adenopathy
- Tonsillar exudate, OR
- Positive test for GAS
When to Use Watchful Waiting
- Use watchful waiting if episodes fall below Paradise criteria thresholds, as spontaneous improvement commonly occurs (control groups showed reduction to only 0.3-1.17 episodes per year without surgery) 1, 2
Follow-Up Management
Do NOT perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 2, 3
If symptoms persist despite appropriate therapy, consider: medication non-compliance, chronic GAS carriage with intercurrent viral infections, or need for alternative antibiotics 2, 3
Critical Pitfalls to Avoid
Never initiate antibiotics without confirming GAS infection through testing 1, 2, 3
Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 2, 3
Never prescribe antibiotic courses shorter than 10 days for GAS tonsillitis, as this increases risk of treatment failure and does not prevent rheumatic fever 1, 2, 3, 5
Never perform tonsillectomy without meeting appropriate frequency and documentation criteria (Paradise criteria) 1, 2, 3
Do not prescribe antibiotics for viral tonsillitis 1