What is the management of tonsillitis?

Management of Tonsillitis

For acute tonsillitis, confirm bacterial infection with rapid antigen detection testing or throat culture before prescribing antibiotics, then treat confirmed Group A Streptococcus with penicillin V or amoxicillin for 10 days, while viral tonsillitis requires only supportive care. 1, 2

Diagnostic Approach

Distinguish viral from bacterial infection before initiating treatment:

• Bacterial tonsillitis presents with sudden onset sore throat, fever >38°C (101°F), tonsillar exudates, tender anterior cervical lymphadenopathy, and notably absence of cough 1, 2
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy 1, 2
• Always perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus before prescribing antibiotics 1, 2
• Do not initiate antibiotics based on clinical presentation alone without microbiologic confirmation 1, 2

Treatment of Confirmed Bacterial (GAS) Tonsillitis

First-Line Antibiotic Therapy

Penicillin V remains the gold standard:

• Penicillin V oral for 10 days is the first-line treatment for confirmed GAS tonsillitis 1, 2
• Amoxicillin for 10 days is an equivalent alternative 1, 2
• The full 10-day course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis 1, 2
• Short courses (5 days) of standard-dose penicillin are less effective for GAS eradication and should be avoided 1

Penicillin-Allergic Patients

Tailor antibiotics based on allergy severity:

• For non-anaphylactic penicillin allergy: first-generation cephalosporins (cefalexin or cefadroxil) for 10 days 1
• For anaphylactic penicillin allergy: clindamycin, azithromycin, or clarithromycin 1
• Azithromycin dosing for pharyngitis/tonsillitis in children ≥2 years: 12 mg/kg once daily for 5 days 3

Supportive Care for All Patients

Provide symptomatic relief regardless of antibiotic use:

• NSAIDs (ibuprofen) or acetaminophen for pain and fever control 1
• Warm salt water gargles for patients capable of performing them 1
• Adequate hydration 4

Management of Recurrent Tonsillitis

Watchful Waiting vs. Surgical Intervention

Use Paradise criteria to guide tonsillectomy decisions:

• Recommend watchful waiting if episodes are <7 in the past year, <5 per year for 2 years, or <3 per year for 3 years 2, 5
• Consider tonsillectomy when meeting Paradise criteria: ≥7 documented episodes in the past year, OR ≥5 per year for 2 consecutive years, OR ≥3 per year for 3 consecutive years 2, 5
• 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, 5
• All episodes must be disabling, adequately treated, and well-documented 2

Alternative Antibiotic Regimens for Treatment Failures

For recurrent documented GAS tonsillitis despite appropriate initial therapy:

• Clindamycin 20-30 mg/kg/day in 3 divided doses (maximum 300 mg/dose) for 10 days 1, 5
• Amoxicillin-clavulanate 40 mg amoxicillin/kg/day in 3 doses (maximum 2000 mg amoxicillin/day) for 10 days 1
• Penicillin V 50 mg/kg/day in 4 doses for 10 days PLUS rifampin 20 mg/kg/day in 1 dose for the last 4 days 1

Chronic GAS Carriers

Recognize that positive tests may not indicate active infection:

• Patients with recurrent positive GAS tests may be chronic carriers experiencing intercurrent viral infections rather than repeated bacterial infections 1, 5
• Up to 20% of asymptomatic school-age children may be GAS carriers during winter and spring 1
• Chronic carriers are unlikely to spread GAS and are at very low risk for complications like rheumatic fever 1
• Do not treat positive GAS tests in asymptomatic carriers or those with viral symptoms (cough, rhinorrhea, hoarseness) 5

Perioperative Management for Tonsillectomy

When surgery is indicated, optimize perioperative care:

• Administer a single intraoperative dose of intravenous dexamethasone for pain relief 6, 2
• Do not routinely administer or prescribe perioperative antibiotics 6

Follow-Up Recommendations

Avoid unnecessary testing:

• Do not perform follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 1, 2
• If symptoms persist despite appropriate therapy, consider medication compliance issues or chronic GAS carriage with intercurrent viral infections 1, 2

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing 1, 2
• Never use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 2
• Never prescribe less than 10 days of antibiotics for GAS tonsillitis, as this increases treatment failure risk 1, 2
• Never perform tonsillectomy without proper documentation meeting Paradise criteria, as many cases resolve spontaneously 5
• Never treat asymptomatic positive GAS tests, as this likely represents chronic carriage rather than active infection 5
• Never use ASO titers to guide treatment decisions or tonsillectomy indications, as they reflect past immunologic response, not current infection 1