What is the treatment for tonsillitis?

From the Guidelines

Tonsillitis treatment should prioritize symptom relief for viral cases and antibiotics for bacterial cases, with penicillin V as the first-line treatment for adults, as recommended by the most recent guidelines 1.

Treatment Approach

The approach to treating tonsillitis depends on whether the cause is viral or bacterial. For viral tonsillitis, which accounts for most cases, treatment focuses on symptom relief. This includes:

• Rest
• Adequate hydration
• Warm salt water gargles
• Over-the-counter pain relievers like acetaminophen (325-650mg every 4-6 hours) or ibuprofen (400-600mg every 6-8 hours)

Bacterial Tonsillitis Treatment

For bacterial tonsillitis, typically caused by Group A Streptococcus, antibiotics are necessary. The first-line treatment is penicillin V (500mg twice daily for 10 days for adults) 1. Alternatives for penicillin-allergic patients include azithromycin (500mg on day 1, then 250mg daily for 4 days) or clindamycin (300mg three times daily for 10 days) 1.

Severe Cases and Tonsillectomy

Severe cases with recurrent infections, breathing difficulties, or abscess formation may require surgical removal (tonsillectomy) 1. The decision for tonsillectomy should be based on documented recurrent throat infections, with a frequency of at least 7 episodes in the past year, at least 5 episodes per year for 2 years, or at least 3 episodes per year for 3 years, along with specific clinical features such as temperature > 38.3°C, cervical adenopathy, tonsillar exudate, or positive test for group A beta-hemolytic streptococcus 1.

Recovery and Prevention

While recovering, patients should consume soft, cool foods and avoid irritants like smoking to help reduce discomfort. Bacterial tonsillitis is contagious until 24 hours after starting antibiotics, so limiting contact with others during this period is advisable. Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis and treat patients with antibiotics only if they have confirmed streptococcal pharyngitis 1.

From the FDA Drug Label

Pharyngitis/Tonsillitis In three double-blind controlled studies, conducted in the United States, azithromycin (12 mg/kg once a day for 5 days) was compared to penicillin V (250 mg three times a day for 10 days) in the treatment of pharyngitis due to documented Group A β-hemolytic streptococci (GABHS or S. pyogenes) Azithromycin was clinically and microbiologically statistically superior to penicillin at Day 14 and Day 30 with the following clinical success (i.e., cure and improvement) and bacteriologic efficacy rates (for the combined evaluable patient with documented GABHS):

Three U. S. Streptococcal Pharyngitis Studies Azithromycin vs. Penicillin V EFFICACY RESULTS Day 14Day 30 Bacteriologic Eradication: Azithromycin323/340 (95%)255/330 (77%) Penicillin V242/332 (73%)206/325 (63%) Clinical Success (Cure plus improvement): Azithromycin336/343 (98%)310/330 (94%) Penicillin V284/338 (84%)241/325 (74%)

Treatment of tonsillitis: Azithromycin is effective in the treatment of pharyngitis/tonsillitis due to documented Group A β-hemolytic streptococci, with a clinical success rate of 98% at Day 14 and 94% at Day 30. The recommended dosage is 12 mg/kg once a day for 5 days.

• Bacteriologic eradication rates were 95% at Day 14 and 77% at Day 30.
• Common side effects include diarrhea/loose stools, vomiting, and abdominal pain. 2

From the Research

Treatment of Tonsillitis

• The treatment of tonsillitis is focused on supportive care, and if group A beta-hemolytic streptococcus is identified, penicillin should be used as the first-line antibiotic 3.
• In cases of recurrent tonsillitis, watchful waiting is strongly recommended if there have been less than seven episodes in the past year, less than five episodes per year for the past two years, or less than three episodes per year for the past three years 3.
• For bacterial tonsillitis, penicillins remain the treatment of choice, and augmented aminopenicillins have gained utility in concert with the increasing incidence of beta-lactamase producing bacteria 4.
• However, it has been found that penicillin may not always be effective in eradicating group A beta-hemolytic streptococci tonsillitis, with bacteriologic failure occurring in up to 20% of patients treated with penicillin 5.
• Other antibiotics such as cephalosporins, clindamycin, macrolides, and amoxicillin-clavulanate have been found to be more effective in eradicating the infection, especially in patients who have failed previous penicillin therapy 5, 6.

Diagnosis of Tonsillitis

• The diagnosis of acute tonsillitis is clinical, and it can be difficult to distinguish viral from bacterial infections 7.
• Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis, but more accurate tests take longer to deliver results 7.
• Symptom-based validated scoring systems, such as the Centor score, and oropharyngeal and serum laboratory testing can be used to diagnose tonsillitis 3.

Management of Recurrent Tonsillitis

• The definition of severe recurrent throat infections is arbitrary, but recent criteria have defined severe tonsillitis as: five or more episodes of true tonsillitis a year; symptoms for at least 1 year; and episodes that are disabling and prevent normal functioning 7.
• Tonsillectomy may be considered in children and adults with acute recurrent or chronic throat infections, with cold-steel tonsillectomy and diathermy tonsillectomy being two possible interventions 7.