What is the treatment for tonsillitis?

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, but only after confirming the diagnosis with rapid antigen detection testing (RADT) or throat culture—never initiate antibiotics empirically without testing. 1, 2

Diagnostic Approach

Always test before treating to avoid unnecessary antibiotic use, as most tonsillitis cases are viral in origin. 2

• Perform rapid antigen detection testing (RADT) and/or throat culture for Group A Streptococcus (GAS) before prescribing any antibiotics. 1, 2, 3
• Look for these specific clinical features suggesting bacterial tonsillitis: sudden onset sore throat, fever >38°C (>38.3°C for surgical criteria), tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 1, 2, 3
• Viral tonsillitis typically lacks high fever, tonsillar exudate, and cervical lymphadenopathy—these patients do not need antibiotics. 2, 3

Critical pitfall: Microbiological screening in asymptomatic children is senseless and does not justify antibiotic treatment, as 10% of healthy children carry Streptococcus pyogenes without clinical disease. 4, 5

Medical Treatment Algorithm

First-Line Antibiotic Therapy (Confirmed GAS Only)

Penicillin V remains the gold standard despite some treatment failures, as it prevents rheumatic fever and glomerulonephritis. 1, 2

• Adults: Penicillin V 250 mg four times daily OR 500 mg every 12 hours for 10 days. 6
• Children: 30-50 mg/kg/day divided into equal doses for 10 days (may double for severe infections, not exceeding 4 g/day). 6
• Alternative first-line: Amoxicillin for 10 days is acceptable. 1, 2

The full 10-day course is mandatory—shorter courses may resolve symptoms but fail to prevent rheumatic fever and glomerulonephritis, even though symptom reduction may be comparable. 1, 2, 5

Penicillin-Allergic Patients

• Non-anaphylactic allergy: Use first-generation cephalosporins. 2
• Anaphylactic allergy: Use clindamycin, azithromycin, or clarithromycin. 2
• Azithromycin dosing (children): 12 mg/kg once daily for 5 days showed 95% bacteriologic eradication at Day 14 versus 73% with penicillin V, though long-term cure rates (Day 30) were 77% versus 63%. 7

Important caveat: While azithromycin and other macrolides show superior short-term eradication rates, only the 10-day penicillin course has proven effectiveness in preventing rheumatic fever. 5 The incidence of rheumatic heart disease is currently 0.5 per 100,000 school-aged children. 4, 5

Supportive Care (All Patients)

• Provide acetaminophen or ibuprofen for pain and fever control. 1
• Ensure adequate hydration. 1
• Consider dexamethasone for additional pain relief in severe cases. 3, 4, 5

Surgical Treatment: Tonsillectomy

Indications (Paradise Criteria)

Tonsillectomy is indicated when recurrent bacterial tonsillitis meets these specific frequency thresholds 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

Each documented episode must include: temperature >38.3°C, cervical adenopathy, tonsillar exudate, OR positive test for GAS. 1, 2

When to Avoid Surgery

• Watchful waiting is appropriate 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
• For children under 6 years, tonsillectomy should only be performed for recurrent acute bacterial tonsillitis meeting Paradise criteria—for tonsillar hyperplasia, partial tonsillectomy (tonsillotomy) is first-line with lower hemorrhage risk. 4, 5

Special Surgical Indications

Total extracapsular tonsillectomy remains indicated for: 4, 5

• Recurrent infections meeting Paradise criteria with antibiotic allergy
• PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, cervical adenitis)
• Peritonsillar abscess

Follow-Up and Monitoring

• 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
• Beta-lactamase-producing bacteria (BLPB) were recovered from over 75% of tonsils in patients with recurrent infection and may "shield" GAS from penicillin—in these cases, consider amoxicillin-clavulanate, cephalosporins, or clindamycin. 8

Critical Pitfalls to Avoid

• Never initiate antibiotics without confirming GAS infection through testing—this leads to unnecessary antibiotic use in viral cases. 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 treatment failure risk and fails to prevent rheumatic fever. 1, 2, 3
• Never perform tonsillectomy without meeting appropriate frequency and documentation criteria (Paradise criteria). 1, 2, 3