What is the recommended treatment for tonsillitis?

Treatment of Tonsillitis

For confirmed bacterial (Group A Streptococcus) tonsillitis, penicillin V 50 mg/kg/day divided into 3-4 doses for 10 days is the first-line treatment, while viral tonsillitis requires only supportive care with NSAIDs or acetaminophen. 1, 2

Diagnostic Approach Before Treatment

Testing is mandatory before prescribing antibiotics - never initiate antibiotics without confirming Group A Streptococcus (GAS) infection through rapid antigen detection testing (RADT) and/or throat culture. 1, 2

Clinical Features Suggesting Bacterial vs. Viral Etiology

Bacterial tonsillitis (GAS) presents with:

• Sudden onset of sore throat 1
• Fever >38°C (>38.3°C is more specific) 1, 2
• Tonsillar exudates 1
• Tender anterior cervical lymphadenopathy 1
• Absence of cough (key distinguishing feature) 1, 3

Viral tonsillitis typically lacks:

• High fever 1
• Tonsillar exudate 1
• Cervical lymphadenopathy 1

First-Line Antibiotic Treatment for Confirmed GAS

Penicillin V remains the gold standard:

• Dose: 50 mg/kg/day divided into 3-4 doses (maximum varies by formulation) 1
• Duration: 10 full days - this is non-negotiable for maximizing bacterial eradication and preventing rheumatic fever 1, 2
• Do not use 5-day courses of standard-dose penicillin - they are significantly less effective for GAS eradication 1, 3

Alternative first-line option:

• Amoxicillin 40 mg/kg/day divided into 3 doses for 10 days (maximum 2000 mg/day) 1, 2

Treatment for Penicillin-Allergic Patients

For non-anaphylactic penicillin allergy:

• First-generation cephalosporins (cephalexin or cefadroxil) for 10 days 1, 3

For anaphylactic penicillin allergy:

• Clindamycin 20-30 mg/kg/day in 3 doses (maximum 300 mg/dose) for 10 days 1, 3
• Azithromycin 12 mg/kg once daily for 5 days (for pharyngitis/tonsillitis in children ≥2 years) 4
• Clarithromycin 1, 3

Supportive Care for All Patients

Regardless of whether antibiotics are prescribed, all patients require symptomatic treatment:

• Ibuprofen or acetaminophen for pain and fever control 1, 2, 3
• Adequate hydration 2
• Warm salt water gargles (for patients old enough to perform them) 1

Management of Treatment Failure or Recurrent Tonsillitis

If symptoms return within 2 weeks of completing therapy, consider:

• Clindamycin 20-30 mg/kg/day in 3 doses for 10 days 1
• Amoxicillin-clavulanate 40 mg amoxicillin/kg/day in 3 doses for 10 days 1
• Penicillin V with rifampin (rifampin added for last 4 days of 10-day penicillin course) 1

Important consideration: Quick symptom recurrence may indicate chronic GAS carriage with intercurrent viral infection rather than true bacterial reinfection. 1 Up to 20% of asymptomatic school-age children may be GAS carriers during winter and spring. 1

Indications for Tonsillectomy

Tonsillectomy should be considered when meeting Paradise criteria:

• ≥7 documented episodes in the past year, OR 1, 2, 3
• ≥5 documented episodes per year for 2 consecutive years, OR 1, 2, 3
• ≥3 documented episodes per year for 3 consecutive years 1, 2, 3

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

Watchful waiting is strongly recommended if episodes fall below these thresholds - spontaneous improvement commonly occurs without surgery. 2, 5

Tonsillectomy is NOT recommended solely to reduce frequency of GAS pharyngitis without meeting these specific criteria. 1, 2

Critical Pitfalls to Avoid

• Never prescribe antibiotics without confirming GAS infection through testing - this drives antibiotic resistance and is ineffective for viral tonsillitis 1, 2
• Never use less than 10 days of penicillin - shorter courses increase treatment failure risk and do not prevent rheumatic fever 1, 2, 3
• Do not use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 2
• Do not perform routine follow-up throat cultures in asymptomatic patients who completed appropriate therapy 1
• Do not rely on ASO titers to guide acute treatment decisions - they reflect past immunologic response, not current infection 1