Tonsillitis Treatment Protocol
Immediate Diagnostic Approach
Test before treating: perform rapid antigen detection test (RADT) and/or throat culture for Group A Streptococcus (GAS) before initiating any antibiotics. 1, 2, 3
Clinical Features Suggesting Bacterial (GAS) Tonsillitis:
- Sudden onset sore throat 1, 2
- Fever >38°C (specifically >38.3°C for documentation) 1, 3
- Tonsillar exudates 1, 2, 3
- Tender anterior cervical lymphadenopathy 1, 2, 3
- Absence of cough (key distinguishing feature) 1, 2
Viral Tonsillitis Characteristics:
- Typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy 2
- Accounts for 70-95% of tonsillitis cases 4
First-Line Antibiotic Treatment for Confirmed GAS Tonsillitis
Penicillin V 1000 mg three times daily for 10 days is the gold standard treatment for confirmed bacterial tonsillitis. 1, 2, 3
Alternative First-Line Option:
Critical Treatment Principle:
The full 10-day antibiotic course is mandatory to maximize bacterial eradication and prevent rheumatic fever and glomerulonephritis, even if symptoms resolve earlier. 1, 2
Penicillin-Allergic Patients
Non-Anaphylactic Penicillin Allergy:
Anaphylactic Penicillin Allergy:
Note: Azithromycin demonstrated 98% clinical success at Day 14 and 94% at Day 30 for streptococcal pharyngitis/tonsillitis, compared to 84% and 74% respectively for penicillin V in FDA trials. 5
Supportive Care (All Patients)
- Acetaminophen or ibuprofen for pain and fever control 1
- Adequate hydration 1
- Educate caregivers about pain management and reassessment 1
Management of Recurrent Tonsillitis
Watchful Waiting Criteria (Recommended First):
Watchful waiting is strongly recommended if episodes fall below these thresholds, as spontaneous improvement commonly occurs (reduction to only 0.3-1.17 episodes per year without surgery). 1
- Fewer than 7 episodes in the past year 1, 2, 4
- Fewer than 5 episodes per year for 2 consecutive years 1, 2, 4
- Fewer than 3 episodes per year for 3 consecutive years 1, 2, 4
Tonsillectomy Criteria (Paradise Criteria):
Consider tonsillectomy when meeting all of the following: 1, 2, 3
- ≥7 documented episodes in the past year, OR
- ≥5 documented episodes per year for 2 consecutive years, OR
- ≥3 documented episodes per year for 3 consecutive years
Each episode must be documented in the medical record with at least one of: 1, 2, 3
- Temperature >38.3°C
- Cervical adenopathy
- Tonsillar exudate
- Positive test for GAS
Follow-Up and Monitoring
- Do not perform routine follow-up throat cultures for asymptomatic patients who completed appropriate antibiotic therapy 2
- If symptoms persist despite appropriate therapy, consider: 2
- Medication non-compliance
- Chronic GAS carriage with intercurrent viral infections
- Need for alternative antibiotics
Critical Pitfalls to Avoid
Never:
- Initiate antibiotics without confirming GAS infection through testing 1, 2
- Use broad-spectrum antibiotics when narrow-spectrum penicillins are effective for confirmed GAS 1, 2
- Prescribe antibiotic courses shorter than 10 days for GAS tonsillitis (increases treatment failure risk) 1, 2
- Perform tonsillectomy without meeting appropriate frequency and documentation criteria 1, 2
- Prescribe antibiotics for viral tonsillitis 1
One notable exception: A 2019 randomized controlled trial demonstrated that penicillin V 800 mg four times daily for 5 days was non-inferior to the standard 10-day regimen, with 89.6% vs 93.3% clinical cure rates and similar complication rates. 6 However, current guideline recommendations remain 10 days until this evidence is formally incorporated into practice guidelines.